Tuesday, February 25, 2014

‘High desire’, or ‘merely’ an addiction? A response to Steele et al. by Donald L. Hilton, Jr., MD

Donald L. Hilton, Jr., MD*

Department of Neurosurgery, The University of Texas Health Sciences Center at San Antonio, USA

Published: 21 February 2014

Socioaffective Neuroscience & Psychology 2014. © 2014 Donald L. Hilton. This is an Open Access article distributed under the terms of the Creative Commons CC-BY 4.0 License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

Citation: Socioaffective Neuroscience & Psychology 2014, 4: 23833 – http://dx.doi.org/10.3402/snp.v4.23833


The validity of an argument depends on the soundness of its premises. In the recent paper by Steele et al., conclusions are based on the initial construction of definitions relating to ‘desire’ and ‘addiction’. These definitions are based on a series of assumptions and qualifications, the limitations of which are acknowledged by the authors initially, but inexplicably ignored in reaching the firm conclusions the authors make. Yet, the firmness of these conclusions is unwarranted, not only as a result of conceptually problematic initial premises but also due to problematic methodology.

Consider, for instance, the concept of ‘sexual desire’. The first paragraph acknowledges that ‘sexual desires must be consistently regulated to manage sexual behaviors’, and must be controlled when either illegal (pedophilia) or inappropriate (infidelity). The paragraph ends with the inference that the term ‘sexual addiction’ does not describe a problematic entity per se, but that it merely describes a subset of individuals with high levels of desire.

The next paragraph references a paper by Winters et al., which suggests that ‘dysregulated sexuality … may simply be a marker of high sexual desire and the distress associated with managing a high degree of sexual thoughts, feelings, and needs’ (Winters, Christoff, & Gorzalka, 2010). It is based on these assumptions that Steele et al. then proceeds to question a disease model for this ‘distress’ associated with controlling sexual ‘desire’. For a comparison of different ‘desire’ templates, television viewing in children is used as an example. The last two sentences in this paragraph establish the premise that the rest of the paper then tries to prove:
Treatments focus on reducing the number of hours viewing television behaviorally without a disease overlay such as ‘television addiction’ and are effective. This suggests a similar approach might be appropriate for high sexual desire if the proposed disease model does not add explanatory power beyond merely high sexual desire. (Steele, Staley, Fong, & Prause, 2013)
Based on this comparison, that of desire to watch TV in children and desire for sex in adults, the authors then launch into a discussion on event-related potentials (ERPs) and a subsequent description of their study design, followed by results and discussion, and culminating in the following summary:
In conclusion, the first measures of neural reactivity to visual sexual and non-sexual stimuli in a sample reporting problems regulating their viewing of similar stimuli fail to provide support for models of pathological hypersexuality, as measured by questionnaires. Specifically, differences in the P300 window between sexual and neutral stimuli were predicted by sexual desire, but not by any (of three) measures of hypersexuality. (Steele et al., 2013)
With this statement the authors put forward the premise that high desire, even if it is problematic to those who experience it, is not pathologic, no matter the consequence.

Others have described significant limitations of this study. For instance, author Nicole Prause stated in an interview, ‘Studies of drug addictions, such as cocaine, have shown a consistent pattern of brain response to images of the drug of abuse, so we predicted that we should see the same pattern in people who report problems with sex if it was, in fact, an addiction’. John Johnson has pointed out several critical issues with this use of the Dunning et al. (2011) paper she cites as a basis for comparison with the Steele et al. paper. First, the Dunning et al. paper used three controls: abstinent cocaine users, current users, and drug naïve controls. The Steele et al. paper had no control group of any kind. Second, the Dunning et al. paper measured several different ERPs in the brain, including early posterior negativity (EPN), thought to reflect early selective attention, and late positive potential (LPP), thought to reflect further processing of motivationally significant material. Furthermore, the Dunning study distinguished the early and late components of the LPP, thought to reflect sustained processing. Moreover, the Dunning et al. paper distinguished between these different ERPs in abstinent, currently using, and healthy control groups. The Steele et al. paper, however, looked only at one ERP, the p300, which Dunning compared to the early window of the LLP. The Steele et al. authors even acknowledged this critical flaw in design: ‘Another possibility is that the p300 is not the best place to identify relationships with sexually motivating stimuli. The slightly later LPP appears more strongly linked to motivation’. Steel et al. admit that they are in fact not able to compare their results to the Dunning et al. study, yet their conclusions effectively make such a comparison. Regarding the Steele et al. study, Johnson summarized, ‘The single statistically significant finding says nothing about addiction. Furthermore, this significant finding is a negative correlation between P300 and desire for sex with a partner (r=−0.33), indicating that P300 amplitude is related to lower sexual desire; this directly contradicts the interpretation of P300 as high desire. There are no comparisons to other addict groups. There are no comparisons to control groups. The conclusions drawn by the researchers are a quantum leap from the data, which say nothing about whether people who report trouble regulating their viewing of sexual images have or do not have brain responses similar to cocaine or any other kinds of addicts’ (personal communication, John A. Johnson, PhD, 2013).

Although other serious deficiencies in this study design include lack of an adequate control group, heterogeneity of study sample, and a failure to understand the limitations of the ability of the P300 to qualitatively and quantitatively discriminate and differentiate between ‘merely high sexual desire’ and pathologically unwanted sexual compulsions, perhaps the most fundamental flaw relates to the use and understanding of the term ‘desire’. It is clear that in constructing this definitional platform, the authors minimize the concept of desire with the word ‘merely’. Desire, as related to biological systems in the context of sexuality, is a complex product of mesencephalic dopaminergic drive with telencephalic cognitive and affective mediation and expression. As a primal salience factor in sex, dopamine is increasingly recognized as a key component in sexual motivation, which has been widely conserved in the evolutionary tree (Pfaus, 2010). Genes relating to both the design and expression of sexual motivation are seen across phyla and also span intra-phyla complexity. While there are obvious differences between sex, food seeking, and other behaviors, which are essential to evolutionary fitness, we now know there are similarities in the molecular machinery from which biologically beneficial ‘desire’ emanates. We now know that these mechanisms are designed to ‘learn’, in a neural connecting and modulating way. As Hebb’s law states, ‘Neurons that fire together, wire together’. We became aware of the brain’s ability to alter its structural connectivity with reward learning in early studies relating to drug addiction, but have now seen neuronal reward-based learning with such seemingly diverse natural desires relating to sex and salt craving.

Definitions relating to desire are important here; biological salience, or ‘wanting’, is one thing, whereas we consider ‘craving’ to have more ominous implications as it is used in the literature relating to drug addiction and relapse. Evidence demonstrates that craving states relating to appetites for biologically essential necessities such as salt and sex invoke – with deprivation followed by satiation – a neuroplastic process involving a remodeling and arborizing of neuronal connections (Pitchers et al., 2010; Roitman et al., 2002). Notably, a desperate desire is effected by craving states associated with conditions that portend the possible death of the organism such as salt deficiency, which induces the animal to satiate and avoid death. Drug addiction in humans, interestingly, can affect a comparable craving leading to a similar desperation to satiate in spite of the risk of death, an inversion of this elemental drive. A similar phenomenon occurs with natural addictions as well, such as the individual with morbid obesity and severe cardiac disease continuing to consume a high fat diet, or one with a sexual addiction continuing to engage in random sexual acts with strangers despite an elevated probability of acquiring sexually transmitted diseases such as HIV and hepatitis. That gene sets driving signaling cascades essential to this craving conundrum are identical for both drug addiction and the most basic of natural cravings, salt, supports a hijacking, usurping role for addiction (Liedtke et al., 2011). We also better understand how complex systems associated with and effecting these changes involve genetic molecular switches, products, and modulators such as DeltaFosB, orexin, Cdk5, neural plasticity regulator activity-regulated cytoskeleton-associated protein (ARC), striatally enriched protein tyrosine phosphatase (STEP), and others. These entities form a complex signaling cascade, which is essential to neural learning.

What we experience affectively as ‘craving’, or very ‘high desire’, is a product of mesencephalic and hypothalamic impetus which projects to, participates in, and is part of cortical processing resulting from this convergence of conscious and unconscious information. As we demonstrated in our recent PNAS paper, these natural craving states ‘likely reflect usurping of evolutionary ancient systems with high survival value by the gratification of contemporary hedonic indulgences’ (Liedtke et al., 2011, PNAS), in that we found that these same salt ‘craving’ gene sets were previously associated with cocaine and opiate addiction. The cognitive expression of this ‘desire’, this focus on getting the reward, the ‘craving’ to experience satiation again is but a conscious ‘cortical’ expression of a deeply seated and phyolgenetically primitive drive originating in the hypothalamic/mesencephalic axis. When it results in an uncontrolled and – when expressed – destructive craving for a reward, how do we split neurobiological hairs and term it ‘merely’ high desire rather than addiction?

The other issue relates to immutability. Nowhere in the Steele et al. paper is there a discussion as to why these individuals have ‘high desire’. Were they born that way? What is the role, if any, of environment on both qualitative and quantitative aspect of said desire? Can learning affect desire in at least some of this rather heterogeneous study population? (Hoffman & Safron, 2012). The authors’ perspective in this regard lacks an understanding of the process of constant modulation at both cellular and macroscopic levels. We know, for instance, that these microstructural changes seen with neuronal learning are associated with macroscopic changes as well. Numerous studies confirm the importance of plasticity, as many have compellingly argued: ‘Contrary to assumptions that changes in brain networks are possible only during critical periods of development, modern neuroscience adopts the idea of a permanently plastic brain’ (Draganski & May, 2008); ‘Human brain imaging has identified structural changes in gray and white matter that occur with learning … learning sculpts brain structure’ (Zatorre, Field, & Johansen-Berg, 2012).

Finally, consider again the author’s term ‘merely high sexual desire’. Georgiadis (2012) recently suggested a central dopaminergic role for humans in this midbrain to striatum pathway. Of all the natural rewards, sexual orgasm involves the highest dopamine spike in the striatum, with levels up to 200% of baseline (Fiorino & Phillips, 1997), which is comparable with morphine (Di Chiara & Imperato, 1988) in experimental models. To trivialize, minimize, and de-pathologize compulsive sexuality is to fail to understand the central biological role of sexuality in human motivation and evolution. It demonstrates a naiveté with regard to what is now an accepted understanding of current reward neuroscience, in that it pronounces sexual desire as inherent, immutable, and uniquely immune from the possibility of change either qualitatively or quantitatively. Even more critically, however, as illustrated by the Steele et al. paper, is that this myopic dogma fails to comprehend the truth that neuroscience now tells us that ‘high desire’, when it results in compulsive, unwanted, and destructive behavior, is ‘merely’ an addiction.


Di Chiara, G., & Imperato, A. (1988). Drugs abused by humans preferentially increase synaptic dopamine concentrations in the mesolimbic system of freely moving rats. Proceedings of the National Academy of Sciences, 85(14), 5274–5278. Publisher Full Text
Draganski, B., & May, A. (2008). Training-induced structural changes in the adult human brain. Behavioral Brain Research, 192(1), 137–142. Publisher Full Text
Dunning, J. P., Parvaz, M. A., Hajcak, G., Maloney, T., Alia-Klein, N., Woicik, P. A., et al. (2011). Motivated attention to cocaine and emotional cues in abstinent and current cocaine users: An ERP study. European Journal of Neuroscience, 33(9), 1716–1723. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
Fiorino, D. F., & Phillips, A. G. (1997). Dynamic changes in nucleus accumbens dopamine efflux during the Coolidge Effect in male rats. Journal of Neuroscience, 17(12), 4849–4855. PubMed Abstract
Georgiadis, J. R. (2012). Doing it … wild? On the role of the cerebral cortex in human sexual activity. Socioaffective Neuroscience and Psychology, 2, 17337. Publisher Full Text
Hoffman, H., & Safron, A. (2012). Introductory editorial to ‘The Neuroscience and Evolutionary Origins of Sexual Learning’. Socioaffective Neuroscience and Psychology, 2, 17415.
Liedtke, W. B., McKinley, M. J., Walker, L. L., Zhang, H., Pfenning, A. R., Drago, J., et al. (2011). Relation of addiction genes to hypothalamic gene changes subserving genesis and gratification of a classic instinct, sodium appetite. Proceedings of the National Academy of Sciences, 108(30), 12509–12514. Publisher Full Text
Pfaus, J. G. (2010). Dopamine: Helping males copulate for at least 200 million years. Behavioral Neuroscience, 124(6), 877–880. PubMed Abstract | Publisher Full Text
Pitchers, K. K., Balfour, M. E., Lehman, M. N., Richtand, N. M., Yu, L., & Coolen, L. M. (2010). Neuroplasticity in the mesolimbic system induced by natural reward and subsequent reward abstinence. Biological Psychiatry, 67, 872–879. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
Roitman, M. F., Na, E., Anderson, G., Jones, T. A., & Berstein, I. L. (2002). Induction of a salt appetite alters dendritic morphology in nucleus accumbens and sensitizes rats to amphetamine. Journal of Neuroscience, 22(11), RC225: 1–5.
Steele, V. R., Staley, C., Fong, T., & Prause, N. (2013). Sexual desire, not hypersexuality, is related to neurophysiological responses elicited by sexual images. Socioaffective Neuroscience and Psychology, 3, 20770. Publisher Full Text
Winters, J., Christoff, K., & Gorzalka, B. B. (2010). Dysregulated sexuality and high sexual desire: Distinct constructs? Archives of Sexual Behavior, 39(5), 1029–1043. PubMed Abstract | Publisher Full Text
Zatorre, R. J., Field, R. D., & Johansen-Berg, H. (2012). Plasticity in gray and white: Neuroimaging changes in brain structure during learning. Nature Neuroscience, 15, 528–536. PubMed Abstract | PubMed Central Full Text | Publisher Full Text
*Donald L. Hilton
4410 Medical Drive
Suite 610
San Antonio
Texas, 77829
Email: dhiltonjr@sbcglobal.net
Original post: http://www.socioaffectiveneuroscipsychol.net/index.php/snp/article/view/23833/32589

Monday, July 29, 2013

"Don’t Call it Hypersexuality: Why we Need the Term Sex Addiction," By Linda Hatch, PhD

What does it mean to say that sex addiction “exists” or “doesn’t exist” apart from the fact that denying its existence or rebutting the denials can get you your 15 minutes of fame.
A diagnostic term is always a provisional construct, a tool for organizing information about phenomena we are trying to understand and work with.  A construct will be “correct” as long as it is optimally useful.

A recent study at UCLA came out with the conclusion that that people with problematic porn use may not be “sex addicts” and that they might just have a high “sexual desire.”  They admitted this was a very tentative conclusion, and they hinted that no useful conclusions about sex addiction are yet supported by the data they collected.  But the headlines sound so important.  Sex addiction doesn’t exist!

The study did an EEG test on people who reported problems with porn use and found that their brains did not respond the way the researchers hypothesized they would.  From this the researchers concluded that people with problem porn use may not be addicts.  This is a gross oversimplification of a study that is too convoluted and confusingly designed to go into in any detail without putting you and myself to sleep.

The response to this study was that it was, to say the least, no big deal.

An article in PsychologyToday.com by a colleague of the researcher brings out some of the many questionable aspects of the study.  Other articles such as a critique by Dr. Rory Reid, and a critique on PornStudySkeptics, have attempted to actually address the  problems with the study such as the lack of a control group, the use of certain questionnaires, the limitation of the subjects to porn use rather than including other forms of sexually addictive behavior, the use of still photos as sexual stimuli, the use of content that was one woman and one man having sex, and the use of the comparison with a past study of the same EEG response in cocaine addicts viewing pictures related to drugs.

The question that we need to ask is “is the term sex addiction the most useful way to describe a set of behaviors and experiences from a clinical and research standpoint?”  I think the answer at this point in history is “yes”.

Theoretical constructs
When we use words to describe phenomena in science and medicine we look for a construct that can be consistently tied to some quantifiable data and that works as an accurate description of the specific set of facts we are trying to work on.  Then we use that term as long as it is the most productive construct around, productive in terms of helping us understand things and organize our research questions in such a way as to push our knowledge forward. That construct will be correct as long as it is useful.  (I am deliberately leaving out consideration of the DSM criteria for addiction, tolerance, withdrawal etc. as they may or may not end up being critical to the research and treatment issues.)

I believe that the term sex addiction is by far the most useful and productive way to think about the phenomenon and that the alternatives are misleading in terms of how we use the terms in clinical work and research.

“Hypersexuality” is a useful way to describe a symptom more than it is a description of a disease entity.  It is a symptom of dozens of other disorders including everything from bipolar disorder to brain damage.  It has no “face validity,” meaning it doesn’t seem like it alone can describe what our patients are experiencing.  It may have seemed like a way to get sexual addiction into the DSM which would have been useful in its own right had it happened.

“High sexual desire” and “high sex drive” are similarly not very useful.  Sex is overly important to sex addicts but to apply the label “high desire” has no established explanatory power in this area and in fact is circular.

Some of our colleagues argue that the person who struggles with the shame and ravages of sex addiction is simply amoral or irresponsible.  This position is totally useless and  does nothing to push forward the frontiers of knowledge.  (See also my blog “Sex Addiction Deniers: What Makes Them So Mad?’)

Some important features of “sex addiction” as a diagnosis
There is a saying that “sex addiction isn’t about sex, it’s about pain.”  For sex addicts sex is a drug to kill pain and escape unpleasant emotions.  It may function like “speed” through amping up general level of arousal, as when engaging in risky activities like hook-ups with strangers or illicit behaviors.  Or it may be used to numb out as with the addict who gets lost in fantasy or porn.  It becomes the addict’s drug of choice.

Addiction has for many years been described as being a pathological relationship with a substance or behavior.  Concepts like hypersexuality appear to be inside the patient.  Presumably someone could have a heightened sex drive without ever doing anything in particular.  Sex addiction is understood as a damaging way of relating to something.

Sex addiction researchers have found that those experiencing sex addiction usually also suffer from other co-addictions as well.  They believe there is a common underlying process that involves the loss of control over the behaviors.  In fact the treatment approach is one that looks for a “primary” addiction but assumes that the person’s other addictions need to be addressed as part of the same treatment process.

Attempting to find a new construct which distinguishes sexually addictive behavior from its fellow-travelers means failing to make use of the great and increasing body of work in the general field of addiction research.  Much useful information can be transposed from findings about gambling, smoking and so on.  And useful hypotheses may emerge from this body of work in the investigation of sex addiction in particular.  But research showing that there is no parallel on one measure does not prove anything.  In fact it would be a tedious and pointless endeavor to try to take all the research findings about addiction over many decades and prove that they do not apply to sex addiction.  And who would want to do that?

See also the recent article on brain science and compulsive sexual behavior: Pornography addiction — a supranormal stimulus considered in the context of neuroplasticity by Donald L. Hilton Jr., MD


Dr. Linda Hatch was born and grew up in New York City and has worked as a licensed clinical psychologist in California since the 1970’s. She completed her BA, MA and PhD at Cornell University and University of California Riverside. She also taught at UCLA as an acting assistant professor and received a post-doctoral fellowship at UCLA in social psychology.

Dr. Hatch has been in private practice combined with teaching and consulting for most of her career. For many years she consulted with the Superior Court, the Probation Department, the Board of Prison Terms, and the State Department of Mental Health during which time she provided forensic assessment and expert testimony as well as psychotherapy. She did considerable work with both adult and juvenile sex offenders, mentally disordered offenders and sexually violent predators both in and outside of the courts and prison system. Her earlier experience also includes several years in university student counseling and crisis intervention/critical incident debriefing. She also worked as a staff psychologist and as training coordinator for the Santa Barbara County Department of Alcohol, Drug and Mental Health Services before choosing to specialize in the field of sex addiction.

Currently Dr. Hatch is in private practice in Santa Barbara as a Certified Sex Addiction Therapist (CSAT). Prior to this she was affiliated with Sexual Recovery Institute in Los Angeles. Her practice is limited to the field of sexual addiction treatment including the treatment of sex addicts and sex offenders, as well as their partners and families.

Dr. Hatch is a member of the American Psychological Association, and the Society for the Advancement of Sexual Health. She received her CSAT certification through the International Institute for Trauma and Addiction Professionals.

Thursday, July 25, 2013

Misinformed Media Touts Bogus Sex Addiction Study, by Robert Weiss, LCSW & Stefanie Carnes PhD

Why the media takes one bad study and distorts its conclusions for shock value.

Published on July 24, 2013 by Robert Weiss, LCSW, CSAT-S in Love and Sex in the Digital Age

In a nationally distributed study published last week, a group of researchers argued that what is often termed as “sexual addiction” could be better understood as a pathological variation of “high sexual desire.” After the publication of this article, a multitude of media outlets suggested that the conclusions of this study demonstrate that there is no scientific basis for the diagnosis of sexual addiction. This has occurred despite the study being the first of its kind, riddled with methodological errors, and at best inconclusive with its findings. Nevertheless, it continues to get a lot of media attention, most likely because it addresses problematic human sexual behavior, which is always a media attention-getter.
In the study, researchers monitored the brain activity (using EEG technology) of 52 men and women who self-reported as having “problems controlling their viewing of sexual images.” The researchers then asked these individuals to look at more than 225 still photos - pictures of everything from violence to people skiing to men and women being sexual together - while the EEG measured their brain activity. Participants also completed several questionnaires about their sexual desire and activity. Essentially, researchers were looking for a correlation between EEG readings and the participants’ scores on the various questionnaires, thinking that any correlations might shed light on whether problematic porn use is caused by addiction (which is in essence a neurobiological dysfunction) or merely a high libido.

Sincethe study’s release, critics have cited numerous flaws in it, including concerns that the sample group differed significantly from treatment-seeking sex addicts and that the individual test subjects were not screened for other possible co-morbid conditions that could have interfered with the results. Additionally, there are serious questions about the strategy used to score one of the instruments in the study, which likely invalidated the measure and distorted the statistics. Basically, the researchers’ determination of a subject’s hypersexuality was primarily based on that individual’s responses to questions about having sex with a partner, whereas the brain scans were used to monitor solo sexual activity. As any sex addict can tell you, there is a huge difference in how most of them feel about and respond to in-the-flesh sex versus on-the-screen activity. The most readily apparent methodological error was the research team’s misuse of the Sexual Desire Inventory (SDI). Oddly, the researchers decided to use only part of this comprehensive questionnaire - inexplicably ignoring the questions about solo sexual activity, which, once again, was the exact activity they were monitoring with the brain scans.

Feeling confused? So are we.

Furthermore, the pre-screening of test subjects was wildly inadequate. The study lumped anyone who reported “issues with porn” into the same category. This means that some of the subjects were not likely porn addicts, while others may have been severely addicted. Adding to the quagmire is the fact that the researchers chose vastly different test subjects - men, women, heterosexuals, and homosexuals - and then showed them all the same heterosexually oriented sexual images (when clearly a gay participant would not respond to heterosexual images in the same way). In addition, the test subjects were shown only still images - hardly the streaming HD videos and live webcam shows that most were likely used to using.
Another criticism is the authors’ reliance on EEGs to measure subjects’ brain activity. Yes, EEGs are a useful scientific tool, but only to a certain extent. The simple truth is EEGs measure brain activity from the outside of the skull, making them the neurological equivalent of a blunt instrument. This is hardly definitive when looking at the complicated interplay of the numerous brain regions involved in the creation and expression of sexual desire (rewards, mood, memory, decision-making, etc.)

So, in a nutshell, this study is inconclusive at best, with conclusions drawn by the authors that don’t correlate to the data.

At least the researchers are not overtly indicating that the issue doesn’t exist. Instead, they argue that the problem is not an addiction and that conceptualizing it as “high sexual desire” would be more accurate. However, these researchers did not study the same areas of the brain or use the same technologies that have been utilized in previous research looking at process (behavioral) addictions. In an article released in the journal Socioaffective Neuroscience and Psychology, Dr. Donald Hilton summarizes much of the brain research that does lead scientists to believe that sex (and other natural processes) can be addictions. For a thorough review of this scientific literature see his article here. None of the brain regions looked at in Dr. Hilton’s work or the studies he cited were discussed or examined in the recently released study.

Amazingly, despite the study’s poor design, bad execution, and obvious limitations, the authors chose to formulate misguided conclusions and publish, even sending out an international press release touting their “achievement.”

Dr. Hilton argues that we are on the brink of a paradigm shift in our conceptualization of process addictions. He states, “During the shift, crisis and tension predominate, clouding the significance of the shift in the present. Nevertheless, the new combined paradigm that amalgamates addictions to both substances and processes is beginning to assert itself.” This assertion is evidenced by the fact that in the PubMed literature database the term “sexual addiction” is used almost three times as often as any other term that describes the disease. So is this current media frenzy simply part of the “crisis and tension” clouding our view during the midst of a shift?

Why is it that when two excellent articles come out, one supporting the addiction framework and one questioning it, that the media hones in on one and distorts its conclusions for shock value? What are the resulting repercussions for the tens of thousands of patients whose reality is denied and invalidated? In the 1980s sex addicts were told by mental health practitioners that their problem didn’t exist. Well, it did exist, and because therapists didn’t help them they created their own support groups, and now that network of “S-fellowships” provides critical, free care to tens of thousands of people daily. So while we as clinicians can continue to argue whether this is an addiction, a compulsion, an impulse control problem, or high sexual desire, we should not be arguing that the problem doesn’t exist. And the media shouldn’t either.

A similar phenomenon occurred with alcoholism at the turn of the century. Alcohol addiction was seen as a “moral failing” brought on by a “lack of willpower.” It wasn’t until many years later, when we began to fully understand the disease concept of addiction, that it became better understood. So why is it that society would rather call sex addicts “womanizers” and “schmucks” than use a paradigm that is helpful?

So, let’s consider the repercussions of our labels… So far we have sex addiction, sexual compulsion, impulse control disorder, hypersexual behavior disorder, out-of-control sexual behavior, problematic sexual behavior, and now a new one: high sexual desire. Using the label “sex addiction” rather than the others has a multitude of advantages. First, it is the language that the clients speak. Clients do not come to therapy because they think they have “hypersexual behavior disorder,” they come because they are “sex addicts.” Second, it is the term most often used by physicians. Third, by using an addiction perspective you can reduce the shame, normalize the behavior, provide lots of ancillary resources and materials, and immerse the client in a community of support that involves accountability and taking responsibility for one’s behavior. In contrast, how are we as therapists to effectively help a patient with his or her “high sexual desire”?

And when did high sexual desire and sexual addiction become mutually exclusive concepts? Simply put, diagnosing a person as having a high sexual desire does not rule out sexual addiction. In fact, the research discussed above does nothing to refute the concept of sexual addiction and the growing body of literature that supports that idea. Either way, until a definitive ruling is out, let’s stick to the label that’s clinically useful (especially since it looks like the majority of the existing research supports that paradigm).

Also see "Don’t Call it Hypersexuality: Why we Need the Term Sex Addiction," By Linda Hatch, PhD
and UCLA's SPAN Lab Touts Empty Porn Study As Ground-Breaking

Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. A licensed UCLA MSW graduate and personal trainee of Dr. Patrick Carnes, he founded The Sexual Recovery Institute in Los Angeles in 1995. He has developed clinical programs for The Ranch in Nunnelly, Tennessee, Promises Treatment Centers in Malibu, and the aforementioned Sexual Recovery Institute in Los Angeles.He has also provided clinical multi-addiction training and behavioral health program development for the US military and numerous other treatment centers throughout the United States, Europe, and Asia.

Dr. Stefanie Carnes, Ph.D. is a licensed marriage and family therapist and an AAMFT approved supervisor. Her area of expertise includes working with patients and families struggling with multiple addictions such as sexual addiction, eating disorders and chemical dependency. Dr. Carnes is also a certified sex addiction therapist and supervisor, specializing in therapy for couples and families struggling with sexual addiction. Currently, she is the president of the International Institute for Trauma and Addiction Professionals. She is also the author of numerous research articles and publications including her books, Mending a Shattered Heart: A Guide for Partners of Sex Addicts, Facing Addiction: Starting Recovery from Alcohol and Drugs, and Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts.

Tuesday, July 23, 2013

Rory Reid Reply & Our Response

Critque of Dr. Nicole Prause Study on Sexual Desire and Hypersexuality
by Dr. Rory Reid
Assistant Professor, Research Psychologist
UCLA Resnick Neuropsychiatric Hospital
Department of Psychiatry, University of California, Los Angeles

NOTE: This Critique also responds to our post "UCLA's SPAN Lab Touts Empty Porn Study As Ground-Breaking". See our reply below Reid's post.

Our Response to Reid:

We're glad to see a response to the questions we raised, even if it poses as a critique of Prause's work while only critiquing her critics. As the points we raised have been danced around, but not answered, we'd like Dr. Reid to ask Dr. Prause to answer the following additional questions:
  1. What was the correlation between the EEG data and the full results of the Sexual Desire Inventory (SDI)? The study duly reports the solo-sex desire figures, but when SPAN Lab then chose not to use them in proclaiming a correlation with "sexual desire," it was the same, in effect, as removing the solo-sex data entirely. This is not how the SDI is designed to be used. One can't ethically take dyadic interest alone and arbitrarily rename it "sexual desire" for purposes of headlines and write-up. Given this statistical sleight-of-hand, regression arguments are entirely meaningless.
  2. Where is the evidence that "dyadic interest alone" is commonly used as a measure of "sexual desire?" Prause keeps claiming this, but the only support the study offers for this claim contradicts her claim (study 1, study 2. Moreover, so do comments from one of the SDI's developers, Ilana Spector, whom we contacted in an effort to understand Prause's claims (once we found the studies cited in it contradicted them). Spector, who assured us that the SDI is intended to be administered as a single unit, said, "The scale was only validated using ALL the items both solitary and dyadic.... The scale was not designed to be used [as it was here] nor was it validated that way."
  3. Please provide citations to addiction neuroscience studies that use "within-subject" control groups of the type Prause claims to have used.
  4. Dr. Reid says, "One issue I might raise is my discomfort with Mr. Wilson's dismissal of EEG as a technology." Where did we dismiss EEG as a technology? In fact, our reply has links to 2 studies that used EEGs narrowly and competently in investigating substance addictions. We merely pointed out that, unlike chemical addictions, sexual-behavior addictions entail multiple cognitive inputs. Making broad claims based on EEG activation is reckless because of the inherent limitations of the technology.
  5. Please ask Prause why she mischaracterized her study's EEG findings in her Psychology Today interview, and in her media blitz.
    Prause: "The reason these findings present a challenge is that it shows their brains did not respond to the images like other addicts to their drug of addiction."
    Actually, P300 readings were higher for porn images than for neutral images, which is exactly what would be expected for someone with an addiction. Commenting under the Prause interview, Psychologist John A. Johnson said:
    "My mind still boggles at the Prause claim that her subjects' brains did not respond to sexual images like drug addicts' brains respond to their drug, given that she reports higher P300 readings for the sexual images. Just like addicts who show P300 spikes when presented with their drug of choice. How could she draw a conclusion that is the opposite of the actual results? I think it could be do to her preconceptions--what she expected to find."
    Put simply, the Prause study found signs of addiction - higher response to sexual images - but she misled the media to create false headlines and quotes.

  6. Back to the Sexual Desire Inventory (SDI), and Rory Reid's spin job that we somehow missed the Solitary SDI scores. "Mr. Wilson has attempted to assert that Dr. Prause has failed to sufficiently analyze an SDI subscale used in her study". Read what we actually said, starting here. We clearly stated that no correlation existed when the entire SDI was used. This is a fact. Prause selected only the partner questions to concoct her correlation and her study title, along with her bogus headlines about "sexual desire".

Click to enlarge Table 2

First, the "Note" says the Solitary test score range is  "3-26," and yet the female mean exceeds it. It's 26.46--literally off the charts. What happened?

More important, however, if SPAN Lab had actually measured "sexual desire" using the full SDI, its researchers would have added the very high overall masturbation-desire mean score of 23.92 (out of 26) to the partnered-desire mean score of 58 (of a possible 70). Thus, the true "sexual desire" mean score was a whopping 82 (of a possible 96).

What happens when one compares the actual (14-question) "sexual desire inventory" results with the EEG data? There's no significant correlation at all. No unrealistic claims about dismantling the concept of "sexual desire," no daring media blitz, and no need for all the behind-the-scenes intimidation to try to shore up a flawed finding. In short, Prause's "finding," which contradicts decades of behavioral addiction brain research (including 50 recent brain studies on Internet addicts and videogame addicts alone), would have been a uninteresting null finding (easily explained by other methodological weaknesses).

It's important to note that the study contains a second error in regard to the SDI: "The SDI measures levels of sexual desire using two scales composed of seven items each." In fact, the Sexual Desire Inventory contains nine partnered questions, four solitary questions, and one question that cannot be categorized (#14). The lively media blitz, which accompanied publication of this study, bases its attention-grabbing headlines on partial SDI results. Yet the study write-up contains glaring errors about the SDI itself, which do not engender confidence in the researchers.

Psychology Today and Nicole Prause

Yes, our Psychology Today post was taken down. It's our understanding that it was removed due to groundless legal threats against "Psychology Today," coming from Dr. Prause herself. In fact, a day later, PT removed an earlier post of ours...about another SPAN Lab study. The only posts we have had removed in 4 years of blogging are posts relating to Prause. Hmm. Science thrives on open debate, not this kind of behind-the-scenes intimidation.

Dr. Reid (above) twice linked to our former post on "Psychology Today" (which now shows an unpublished page) and suggested that it had been deleted due to "Psychology Today's" belief that it contained errors. Given that we ourselves have received malicious, unfounded legal threats from Dr. Prause, we very much doubt this.

Although we hate to make emails public, in this case, we feel it is necessary so that interested readers may obtain a fuller picture of Dr. Prause's tactics. See the entire exchange of emails between us and her (below). These occurred months ago, in April, 2013, when she "leaked" an unpublished, not-yet-reviewed version of this study (only) to sympathetic blogger David Ley, author of The Myth of Sex Addiction. She later had "Psychology Today" remove our reply. Incidentally, we then asked "Psychology Today" editors to remove Ley's post based on the leaked study (which Prause had refused to make available to others), and "Psychology Today" did remove it. (Judge for yourself:  Click here to see David Ley's blog post, our reply blog post, and the comments below our post - including Gary's exchange with Nicole Prause.)

When the final study came out, Prause enlisted Brian Mustanski to post a favorable interview, where Prause could "spin" her results to her liking. We posted a reply to his post, and that's what Prause had "Psychology Today" remove.

Keep in mind that Prause had plenty of opportunity to comment on our reply blogs about her two studies (both of which can be found on PornStudySkeptics. Instead, she has chosen not to take us on directly. Now, she has hidden behind Dr. Reid's website commentary, where no direct reply from critics is permitted. 


Prause-Wilson (entire) email exchange

> Reason:
> Other
> 4/10/13
> Message:
> Dear Mr. Wilson,
[In this email, Nicole Prause claimed it was illegal to  misrepresent (sic) her science because we had never requested a copy of the manuscript, and demanded that Gary take down his critique of her study (based on its description by her compadre David Ley).

She added that we should sell our books on our own merit and not try to make money off the backs of scientists doing their jobs, and repeated that it was egregious of Gary not to have asked for a copy of the manuscript. "Shame on you." Actual email available upon request.]

> Nicole Prause, PhD
> Research faculty
> Sender IP:
Nicole Prause, PhD
Research faculty
Department of Psychiatry
760 Westwood Blvd
University of California
Los Angeles, CA 90024 ______@mednet.ucla.edu www.span-lab.com

On Wed, Apr 10, 2013 at 3:14 PM, gary wilson <______@hotmail.com> wrote:

Hi Nicole,

I commented under your comment. Have a look. (link to our exchange)

We make no money on this. My website has no advertising and we accept no donations. We have no services to sell. I have no book to sell. My wife's book, which appears on PT, is not about porn.
If you want to be truly fair, please send us the full study and give us permission to blog about it - as you did with Dr. Ley.

I'll be anticipating your study,

Gary Wilson

From: ______@mednet.ucla.edu Date: Fri, 12 Apr 2013 10:22:53 -0700
Subject: Re: [PT] Inquiry via Psychology Today
To: ______@hotmail.com

Dear Mr. Wilson,

[Nicole Prause threatened Gary with a libel suit for his posting the following perfectly true statement:  
"I responded to her rather nasty emails with a request to see her study, and she refused."
Actual email available upon request.]

Nicole Prause

On Fri, Apr 12, 2013 at 11:09 AM, gary wilson <______@hotmail.com> wrote:

Dear Nicole Prause,

Maybe you didn't know that my wife is a graduate of Yale law school.  I said nothing libelous. In fact, my statements are quite accurate. 

1) You have refused to hand over your unpublished study.
2) You were nasty and threatening, as you are now.
3) In addition, you falsely stated that I make money from guys struggling to recover from porn addiction.
4) You also mischaracterized my PT post , as it was a clear response to David Ley's description of your unpublished study. You chose not correct Ley's description or make the full study available to me, even when I asked about it in the comment section one month ago

You have yet to answer my original questions (posed in the comments section):

1) Why did you release your study to only David Ley? As the author of the "Myth of Sex Addiction," and someone who claims porn addiction cannot exist, why was only he the only Chosen One?
2) Why haven't you corrected David Ley's interpretation of your study? It has been up for over a month, and you've commented twice on it in the last month.
3) You commented under Ley's post one month ago. I immediately posted a comment under you comment, with several specific questions directed to you about your study. That was your chance to both respond and offer the study. You did neither. Why?

I'm fine with making our exchange public.

Won't it be interesting when you file a lawsuit against a couple of PT bloggers who dare to take on your research?

Gary Wilson

From: ______@mednet.ucla.edu Date: Fri, 12 Apr 2013 15:01:09 -0700
Subject: Re: [PT] Inquiry via Psychology Today
To: ______@hotmail.com

Dear Gary,

[In this email Nicole Prause threatened both Gary and Marnia with "actionable harassment" if either contacted her, citing this statute: http://courts.oregon.gov/Lane/Restraining.page). Actual email available upon request.]

Nicole Prause

From: ______@hotmail.com
To: ______@mednet.ucla.edu Subject: RE: [PT] Inquiry via Psychology Today
Date: Fri, 12 Apr 2013 15:44:12 -0700

Dear Nicole Prause,

Harassment? I have not initiated one email exchange with you, including this one.

The first, initiated by you on 4/10/13, where you had the last email. And the one below, where you are trying to create a false impression that someone is harassing you, when in fact you are threatening me for the second time.

You are also the one who contacted Psychology Today's editor to interfere with my blog post. My wife has had no contact with you whatsover.

We do not need your permission.

Gary Wilson

Friday, July 19, 2013

UCLA's SPAN Lab Touts Empty Porn Study As Ground-Breaking

Nothing Correlates With Nothing In SPAN Lab's Latest Porn Study

[This was first published as a reply blog post to a "Psychology Today" blog post that featured an interview with Dr. Nicole Prause, co-author of the study discussed here.]

The authors of this study believe their findings indicate that "hypersexuality" (in this case, inability to control porn use) can be explained by high sexual desire rather than porn addiction. In our view, their data do not remotely support their belief.

Participants: 52 test subjects were recruited through ads "requesting people who were experiencing problems regulating their viewing of sexual images." The participants (average age 24) were a mix of males (39) and females (13). 7 participants were not heterosexual. 

What They Did: EEG readings (electrical activity on the scalp) were taken as participants viewed 225 pictures. 38 of the pictures were sexual, and all involved one woman and one man. This particular EEG reading (P300) measures attentiveness to stimuli.

Participants also completed 4 questionnaires: Sexual Desire Inventory (SDI), Sexual Compulsivity Scale (SCS), Cognitive and Behavioral Outcomes of Sexual Behavior Questionnaire (SBOSBQ), and the Pornography ConsumptionEffect Scale (PCES).

Purpose: To seek a correlation between EEG reading averages and participants' scores on the various questionnaires—on the theory that any correlation would shed light on whether problematic porn use is a function of addiction or mere high libido.

Outcome: The authors of the study claim to have found a single statistically significant correlation among all the data gathered:
"The only correlation reaching significance was the difference score calculated between neutral and pleasant-sexual conditions in the P300 window with the desire for sex with a partner measure."
SPAN Lab presents two conflicting arguments to support its claim that "porn addiction doesn't exist":
  1. On one hand, the researchers argue that a single negative correlation between EEG readings and selected sections of the Sexual Desire Inventory means porn addiction doesn't exist.
  2. On the other hand, they argue that the lack of correlations between EEG readings and 3 other questionnaires means porn addiction doesn't exist.
We will show that:
  1. The single correlation between EEG readings and Sexual Desire Inventory scores claimed by SPAN lab does not actually exist.
  2. The the lack of correlations between EEG and questionnaires is easily explained by a) heterogeneous group of subjects (males, female, non-heterosexuals) viewing straight porn, and  b) questionnaires that do not accurately assess compulsive Internet porn use.

No genuine correlation (or relation) in the study

The study's title, along with the many headlines, state that a correlation (relation) was found between "sexual desire" as measured by the Sexual Desire Inventory and EEG readings. Not so. The correlation was attained by using only certain questions from the Sexual Desire Inventory (SDI) That is, they based their conclusion on the partial SDI data relating to desire for partnered sex.

The Sexual Desire Inventory has questions about desire for masturbation and desire for sex with a partner. "Sexual desire" is a measure of both groups of questions. Here's the key point: no statistically significant correlation was found between scores on the entire Sexual Desire Inventory and EEG readings. Thus there is no support for the study's conclusion that:
"Brain response was only predicted by a measure of sexual desire. In other words, hypersexuality does not appear to explain brain differences in sexual response any more than just having high libido." (From interview with Nicole Prause, corresponding author for the study)
Put simply, when the researchers used the:
1.     SDI questions relating to partnered sex only, they found a slight negative correlation.
2.     When they used the entire SDI, including questions about masturbation, they found no significant correlation.

Had the authors been honest the name of the study would have been: "Sexual Desire is NOT Related to Neurophysiological Responses Elicited by Sexual Images"

There are two massive problems here, which we'll expand on:

1 - Their conclusion is unfounded because, as expanded on below, the researchers constructed an empty correlation. Their supposed correlation was not with "sexual desire" as measured by the SDI (as they claim), but merely with dyadic-interest (a subscale of the test).

2 - The conclusion is based on the astonishing belief that, "If you have high libido you somehow cannot have addiction." In other words, in their view, high libido and addiction are mutually exclusive.

Questionable use of Sexual Desire Inventory (SDI) questionnaire

Keep these key points in mind when reading this complex section:
  1. Only the entire Sexual Desire Inventory  (all 14 questions) is a valid measure of "sexual desire."
  2. The developer of the SDI (Ilana Spector) agrees with #1 above.
  3. Prause stated that the "dyadic questions" have been used before as a measure of "sexual desire." This is false.
  4. Prause cited two studies to support the above claim. Both studies used the entire SDI, not just the dyadic questions.
  5. Prause made two glaring mistakes in describing the Sexual Desire Inventory (SDI)
The questionnaire from which the researchers cherry-picked their partial data was entitled "Sexual Desire Inventory." As a consequence, they took the liberty of creating both an abstract and a study write-up that use the words "sexual desire" repeatedly—63 times in fact. This is not trivial as the abstract implies that the study will find that problem porn users have either sexual "addiction" (quotes supplied by the researchers) or "a non-pathological variation of high sexual desire." (This, again, is the dubious mutually-exclusive hypothesis: either "high sex desire" or "addiction," but not both.)

The study results actually shed no light on which outcome is correct, but the constant use of the term "sexual desire" implies that they have, and that the "high sexual desire" hypothesis was supported by their data. This constant use of the term "sexual desire" leaves the casual reader with the impression that problem porn users merely have "high libido," an impression Prause painstakingly reinforced in the above interview and her press release about the study.

According to everything we can find, the SDI is a 14-question test. Nine of its items address partnered ("dyadic") sexual desire and five address solo ("solitary") sexual desire (not seven and seven, as researchers state).

According to one of its developers, Ilana Spector, the SDI is intended to be administered as a single unit:
"The scale was only validated using ALL the items both solitary and dyadic.... The scale was not designed to be used [as it was here] nor was it validated that way."
The SDI is an "all or none" measuring tool for "sexual desire," not "half."

SPAN Lab itself acknowledges that the only EEG study published on sexual desire used the entire SDI. Yet here, SPAN Lab ignored the data about solitary sex—the very activity their subjects claimed to be unable to control—and constructed a correlation using only the dyadic questions in the test.

The lab suggests that, "The dyadic subscale is commonly used as an index of trait sexual desire level."

This appears to be a lie. Where is the evidence to support this claim? Both studies SPAN Lab lists in support of this untruth used the entire 14-question SDI. (Appetitive Responses to Sexual Stimuli Are Attenuated in Individuals with Low Levels of Sexual Desire and Attention and emotional responses to sexual stimuli and their relationship to sexual desire. The latter was conducted by Prause herself.)

Also notice SPAN Lab's claim that it has measured "trait sexual desire" using (a sub-scale of) the SDI. Spector took issue with this as well,
"I don't think that the word "trait" should be used to describe sexual desire. I think of traits as much more stable characteristics, and sexual desire (both solitary and dyadic) is subject to fluctuations over time, circumstances, etc."
In short, SPAN Lab's claim that it has measured "trait sexual desire" is entirely without foundation. When one adds back the missing scores from the masturbation questions, subjects nearly all report fairly uniform (high) sexual desire, and there is quite likely no statistically significant correlation between their EEG data and anything.

Removing the solo-sex questions is the equivalent of researchers,
  • asking people who couldn't control their eating to describe their food intake over a week,
  •  then throwing out the stats relating to snacking on junk food,
  • and then publishing a conclusion that "Obesity is a function of appetite at mealtime, and unrelated to uncontrolled snacking or addiction."
Undaunted, the researchers then created a headline for their study implying they had found that uncontrolled porn use correlates with "sexual desire." The actual claim is that participants reporting greater desire for partnered sex showed less arousal to visual erotica.

A more telling way to state this pseudo-correlation (based, as it is, on partial sexual-desire data) is that, "Those who find porn the most arousing have least desire for partnered sex." 

This is potentially a sign of psychological problems. As a psychology professor explained to us,
"Desire for dyadic sex indicates a need for intimacy and emotional closeness as well as physical pleasure (a point noted by Spector, one of its developers). Emotional closeness in an intimate relationship is usually regarded as an indication of psychological health. In fact, intimacy and closeness in a relationship is usually regarded as an essential part of what it means to be a human being. So the single significant correlation in the study is pointing to a psychological problem for people who get too wrapped up in sexual images."
Indeed, we have read hundreds of self-reports of heavy Internet porn users who report inability to become aroused by real partners as their porn use escalates. Gay or straight, their interest in real partners and intimacy generally rebounds within weeks or months of quitting Internet porn.

In short, the researchers scored the SDI incorrectly and mislabeled the dyadic-interest score as general "sexual desire." They should not have done that. But, if we go along with their scoring, we find that low interest in intimacy (indicative of poor psychological health) is associated with higher EEG averages in response to sexual images. 

This is not, in fact, a strong argument that subjects' porn use is better explained by "high libido" than "addiction."

Finally, it's important to note that the study contains two errors in regard to the SDI. Quoting the study:
 "The SDI measures levels of sexual desire using two scales composed of seven items each."
 In fact, the Sexual Desire Inventory contains nine partnered questions, four solitary questions, and one question that cannot be categorized (#14).

Second mistake: Table 2 says the Solitary test score range is  "3-26," and yet the female mean exceeds it. It's 26.46--literally off the charts. What happened? The four solitary sex questions (10-13) add up to a possible score of "31".

The lively media blitz, which accompanied publication of this study, bases its attention-grabbing headlines on partial SDI results. Yet the study write-up contains glaring errors about the SDI itself, which do not engender confidence in the researchers.

High desire is mutually exclusive with addiction?

The second major problem with this study is the implication that high sexual desire scores would indicate participants don't have addiction. The concept that "high sexual desire" somehow rules out addiction is astounding. Its irrationality becomes clear if one considers hypotheticals based on other addictions.

For example, does such logic mean that being morbidly obese, unable to control eating, and being extremely unhappy about it, is simply a "high desire for food?" Extrapolating further, one must conclude that alcoholics simply have a high desire for alcohol, right? In short, all addicts have "high desire" for their addictive substances and activities (called "sensitization"), even when their enjoyment of such activities declines due to other addiction-related brain changes (desensitization).

Most addiction experts consider "continued use despite negative consequences" to be the prime marker of addiction. After all, someone could have porn-induced erectile dysfunction and be unable to venture beyond his computer in his mother's basement. Yet, according to these researchers, as long as he indicates "high sexual desire," he has no addiction. This paradigm ignores everything known about addiction, including symptoms and behaviors shared by all addicts, such as severe negative repercussions, inability to control use, cravings, etc.

Is this study part of a rash of studies based on the peculiar logic that any measure of "high desire," however questionable, grants immunity from addiction? A Canadian sexologist endeavored to paint this same picture in a 2010 paper entitled, Dysregulated sexuality and high sexual desire: distinct constructs? Noting that people who seek treatment for sexual behavior addictions report both dysregulated sexuality and high desire, he boldly concluded:

The results of this study suggest that dysregulated sexuality, as currently conceptualized, labelled, and measured, may simply be a marker of high sexual desire and the distress associated with managing a high degree of sexual thoughts, feelings, and needs.

Again, sexual behavior addiction itself produces cravings that often show up as "a high degree of sexual thoughts, feelings, and needs." It's simply wishful thinking to suggest "high sexual desire" disproves the existence of addiction.

In her press release, Prause makes much of the fact that, "The brain's response to sexual pictures was not predicted by any of the three questionnaire measures of hypersexuality."

However, not only is the absence of correlation not causation, there are far more likely explanations for the lack of correlations between the EEG averages and the questionnaires administered. We'll look at them next. 

Studies that directly refute "porn addiction is really high desre" model:
Quote: "Moreover, it was shown that problematic cybersex users report greater sexual arousal and craving reactions resulting from pornographic cue presentation. In both studies, the number and the quality with real-life sexual contacts were not associated to cybersex addiction."
Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn (2014).
This fMRI study found that the more porn the subjects used, the less gray matter in the striatum. The striatum is a complex set of structures. It includes the reward center (ventral striatum) and the dorsal striatum, which also goes by several names. Less gray matter means fewer nerve connections (dendrites and axon terminals) in reward-related areas. Put simply, less gray matter in the striatum mean less reward activity, and a decline in dopamine signaling (desensitization).
Lead author Simone Kühn said -
"That could mean that regular consumption of pornography more or less wears out your reward system."
Simone Kühn continued -
"We assume that subjects with a high porn consumption need increasing stimulation to receive the same amount of reward."
Kühn says existing psychological, scientific literature suggests consumers of porn will seek material with novel and more extreme sex games.
"That would fit perfectly the hypothesis that their reward systems need growing stimulation."

Why no correlations between questionnaires and EEG readings?

Prause's second argument is that the lack of correlations between subjects EEG readings and 3 other questionnaires means porn addiction doesn't exist. Two major reasons account for the lack of correlation:
  1. The researchers chose vastly different subjects (women, men, heterosexuals, non-heterosexuals), but showed them all standard, possibly uninteresting, male+female porn. Put simply, the results of this study are dependent on the premise that males, females, and non-heterosexuals are no different in their response to sexual images. This is false - see below.
  2. The Sexual Compulsivity Scale (SCS) isn't a test of Internet-porn use or porn addiction. In the press, Prause repeatedly pointed to the lack of correlation between EEG scores and sexual compulsivity scales, but there is no reason to expect a correlation in porn addicts.
Unacceptable diversity of test subjects: The researchers chose vastly different subjects (women, men, heterosexuals, non-heterosexuals), but showed them all standard, possibly uninteresting, male+female porn. Standard procedure for addiction studies is to select homogeneous subjects in terms of age, gender and orientation (plus a homogeneous control group) in order to avoid distortions caused by such differences.

An experiment assessing cue-induced reactivity for cocaine might get by with a heterogeneous group males, females and gays, but not a study measuring arousal to porn. This alone explains the lack of correlations. Previous studies confirm large differences between males and females in response to sexual images. See, for example, Gender Differences in Sexual Arousal and Affective Responses to Erotica. and Skin sympathetic nerve activity in humans during exposure to emotionally-charged images: sex difference

Can we be confident that a non-heterosexual has the same enthusiasm for male-female porn as a heterosexual male? No, and his/her inclusion could distort EEG averages rendering meaningful correlations unlikely. See, for example, Neural circuits of disgust induced by sexual stimuli in homosexual and heterosexual men: an fMRI study.

Surprisingly, Prause herself stated in an earlier study that individuals vary tremendously in their response to sexual images:
Film stimuli are vulnerable to individual differences in attention to different components of the stimuli (Rupp & Wallen, 2007), preference for specific content (Janssen, Goodrich, Petrocelli, & Bancroft, 2009) or clinical histories making portions of the stimuli aversive (Wouda et al.,1998).
Still, individuals will vary tremendously in the visual cues that signal sexual arousal to them (Graham,Sanders, Milhausen, & McBride, 2004).
Maybe Prause should read her own statements to discover the reason why her current EEG readings varied so much. Individual differences are normal, and large variations are to be expected with a sexually diverse group of subjects.

Irrelevant questionnaires: The SCS (Sexual Compulsivity Scale) isn't a test of Internet-porn addiction. It was created in 1995 and designed with uncontrolled sexual relations in mind (in connection with investigating the AIDS epidemic). The SCS says:
"The scale has been should [shown?] to predict rates of sexual behaviors, numbers of sexual partners, practice of a variety of sexual behaviors, and histories of sexually transmitted diseases."
Moreover, the SCS's developer warns that this tool won't show psychopathology in women:
"Associations between sexual compulsivity scores and other markers of psychopathology showed different patterns for men and women; sexual compulsivity was associated with indexes of psychopathology in men but not in women."
Furthermore, the SCS includes partner-related questions that Internet-porn addicts might score quite differently compared with sex addicts, given that compulsive porn users often have a far greater appetite for cyber erotica than actual sex.

Another questionnaire the researchers administered is the PCES (Pornography Consumption Effect Scale), which has been called a "psychometric nightmare," and there's no reason to believe it (or the SBOSBQ) can indicate anything about Internet porn addiction or sex addiction.

Thus, the lack of correlation with these questionnaires contributes no support to SPAN Lab's conclusions.

No pre-screening: SPAN Lab's Prause acknowledges that,
"This study only included people who reported problems, ranging from relatively minor to overwhelming problems, controlling their viewing of visual sexual stimuli."
Standard procedure for addiction neuroscientists is to screen subjects with an addiction test in order to compare those who test positive for an addiction with those who do not. These researchers did not do this, even though an Internet porn-addiction test exists.

Instead, researchers administered the Sexual Compulsivity Scale (SCS) after participants were already chosen. They lumped people with minor problems together with those with major problems, averaged their SCS scores, and then made far reaching, entirely unsupported, claims that they had dismantled the concept of porn addiction.

Use of generic porn for diverse group subjects: SPAN Lab admits that its choice of "inadequate" porn may have altered results. Even under ideal conditions, choice of test porn is tricky, as porn users (especially addicts) often escalate through a series of tastes. Many report having little sexual response to porn genres that do not match their porn-du-jour—including genres that they found quite arousing earlier in their porn-watching careers. For example, much of today's porn is consumed via high-definition videos, and the stills used here may not elicit the same response.

Thus, the use of generic porn can affect results. If a porn enthusiast is anticipating viewing porn, dopamine (brain activation) presumably rises. Yet if the porn turns out to be some boring heterosexual pictures that don't match his/her current genre or stills instead of high-definition fetish videos, the user may have little or no response, or even aversion. "What was that?"

This is the equivalent of testing the cue reactivity of bunch of food addicts by serving everyone a single food: baked potatoes. If a participant doesn't happen to like baked potatoes, she must not have a problem with eating too much, right?


More concerns about the study

No control group and serious misrepresentations: The researchers did not investigate a control group of non-problem porn users. Without any evidence of what normal EEG averages would be in response to the erotica they presented, it's impossible to say that the partial-SDI data on which the researchers rely are unique to hypersexuals.

Without a control group, Prause has no idea what a "normal" EEG response to porn should be, yet she is making claims in the press, such as:
 Prause: "The reason these findings present a challenge is that it shows their brains did not respond to the images like other addicts to their drug of addiction."
Actually, P300 readings were higher for porn images than for neutral images, which is exactly what would be expected for someone with an addiction. Commenting under the Psychology Today interview of Prause, Psychologist John A. Johnson said

"My mind still boggles at the Prause claim that her subjects' brains did not respond to sexual images like drug addicts' brains respond to their drug, given that she reports higher P300 readings for the sexual images. Just like addicts who show P300 spikes when presented with their drug of choice. How could she draw a conclusion that is the opposite of the actual results? I think it could be due to her preconceptions--what she expected to find."

In short, what Prause boldly proclaimed in her many media interviews is not backed up by her results. Let's further examine this misrepresentation:
Mustanski: What was the purpose of the study?
Prause: Our study tested whether people who report such problems look like other addicts from their brain responses to sexual images. Studies of drug addictions, such as cocaine, have shown a consistent pattern of brain response to images of the drug of abuse, so we predicted that we should see the same pattern in people who report problems with sex if it was, in fact, an addiction.
Prause's reply to Mustanski indicates that her study was designed to see if the brain response to sexual images for people reporting problems with sex was similar to the brain response of drug users when they encounter images of the drug to which they are addicted.

A reading of the cocaine study she cites (Dunning, et al., 2011), however, indicates that the design of her own study was quite different from the Dunning study, and that her study did not even look for the kind of brain responses recorded in the Dunning study.

The Dunning study used three groups: 27 abstinent cocaine users, 28 current cocaine users, and 29 non-using control subjects. Prause used only one sample of persons: those who reported problems regulating their viewing of sexual images. Whereas the Dunning study was able to compare the responses of cocaine addicts to healthy controls, the Prause study did not compare the responses of the troubled sample with a control group.

But there is more to this slight of hand.

The Dunning study measured several different event-related potentials (ERPs) in the brain, because previous research had indicated important differences in the psychological processes reflected in the ERPs. The study separately measured early posterior negativity (EPN), thought to reflect early selective attention, and late positive potential (LPP), thought to reflect further processing of motivationally significant material. The study further distinguished the early component of LPP, thought to represent initial attention capture, from the later component of LPP, thought to reflect sustained processing. Distinguishing these different ERPs is important because differences among the abstinent addicts, current users, and non-using controls depended on which ERP was being assessed.

In contrast, the Prause study looked only at the ERP called P300, which Dunning compares to the early window of LPP. By their own admission, Prause and her colleagues report that this might not have been the best strategy:
"Another possibility is that the P300 is not the best place to identify relationships with sexually motivating stimuli. The slightly later LPP appears more strongly linked to motivation."
The upshot is that the Prause study did not in fact examine whether the brain responses of sexually troubled individuals "showed the same pattern" as the responses of addicts. They did not use the same ERP variables used in the cocaine study and they did not use an abstinent group and a control group, so they should not have compared their results to the Dunning study claiming the comparison was "apples to apples."

EEG technology limitations: Finally, EEG technology cannot measure the results the researchers claim it can. Although the researchers insist that, "Neural responsivity to sexual stimuli in a sample of hypersexuals could differentiate these two competing explanations of symptoms [evidence of addiction versus high sexual desire]," in fact it's unlikely that EEGs can do this at all. See Brainwashed: The Seductive Appeal of Mindless Neuroscience for a discussion of how EEGs can be misused to draw unfounded conclusions.

EEGs measure electrical activity on the outside of the skull, and addiction researchers who use EEGs look for very narrow signals of specific aspects of addiction. For example, this recent EEG study on Internet addicts shows how accomplished Internet-addiction neuroscientists conduct such experiments. Note that researchers isolate narrow aspects of the brain's activity, such as impulsivity, and avoid overly broad claims of the type made here by SPAN Lab. Also note the control group and pre-screening for addiction, both of which are absent in this SPAN Lab effort.

SPAN Lab seems aware of the technology's inability to distinguish among overlapping cognitive processes:
"The P300 [EEG measurement] is well known and often used to measure neural reactivity to emotional, sometimes sexual, visual stimuli. A drawback to indexing a large, slow ERP component is the inherent nature of overlapping cognitive processes that underlie such a component. In the current report, the P300 could be, and most-likely is, indexing multiple ongoing cognitive processes." (Emphasis added.)
Never mind that, by their own admission, P300 might not be the best choice for an ERP study of this type. Never mind that conducting statistical analyses with difference scores has been recognized as problematic for over 50 years, such that now alternatives to difference scores are usually used (see http://public.kenan-flagler.unc.edu/faculty/edwardsj/Edwards2001b.pdf).  Never mind that we do not really know what the amplitude of P300 to particular images relative to neutral images really signifies. P300 involves attention to emotionally significant information, but as Prause and her colleagues admit, they couldn't predict whether P300 in response to sexual images would be especially elevated for people with high sexual desire (because they experience strong emotions to sexual situations) or whether the P300 would be especially flat (because they were habituated to sexual imagery).

There is a more fundamental problem here: The Prause research team seems to want to take an either/or approach the viewing of sexual images—that ERP responses are either due to sexual desire or to an addictive problem - as if desire can be separated completely from addictive problems. Would anyone suggest that ERP responses in alcoholics or cocaine addicts might be due either entirely to their desire for the addictive substance or to their addictive problem?

Other factors can influence EEG readings. What if an image is related to a genre you like, but the pornstar reminds you of a person you dislike/fear/don't care to see naked. Your brain will have conflicting associations for such erotica. These conflicts may well be more likely in the case of porn images than in the case of, say, cocaine visuals of powder and noses (used when testing cocaine addicts).

The point is that multiple associations with a stimulus as complex as sexuality could easily skew EEG readings.

Also, SPAN Lab assumed higher EEG averages indicate higher sexual arousal, but subjects' EEG averages were in fact all over the map. Is this because some of them were addicts and others not? Or watching porn that turned them off? Many factors can affect P300 readings. Consider the following, from another P300 study:
Although the functional significance of P300 is still debated1, 2, its amplitude indexes the allocation of resources for the evaluation of stimuli....Reduced P300 amplitude has been reported in many psychiatric disorders, including schizophrenia4, depression5, and alcoholism6
In short, SPAN Lab's hypothesis that brains of addicts will show either evidence of addiction or evidence of "high sexual desire" is uninformed. Yet the abstract creates in the reader the impression that the study's results will show us that these hypersexuals either exhibited (1) evidence of addiction or (2) a positive correlation with "high sexual desire." And the study's title then misleadingly proclaims "sexual desire" the winner.


Quite apart from the researchers' splitting a standardized test in order to construct a correlation, no responsible scientist would argue that a study on brain waves, with no control group and no pre-screening for addiction, tells us anything about the existence or absence of addiction or "non-pathological high sexual desire" in subjects suffering from uncontrolled Internet porn use.

One must ask why the study's authors created the abstract's lengthy (misleading) preamble implying they are going to reveal evidence that calls into question the existence of sexual behavior addiction. After all, sexual behavior addiction is a condition that the American Society of Addiction Medicine's 3000+ doctors and researchers publicly affirmed in 2011 based on decades of corroborating neuroscience (including dozens of brain studies on Internet addiction). It seems likely that the current abstract was carefully composed to create the impression in hasty readers (and eager bloggers) that the researchers had somehow "disproven that sexual behavior addictions exist."

Basing far reaching conclusions on dyadic interest alone, while claiming to measure "sexual desire," is a classic bait-and-switch tactic, unworthy of PhDs from UCLA (and elsewhere). 

UPDATE: Nicole Prause TV interview doesn't match study results

As a psychology professor pointed out,
In this TV interview Nicole Prause totally contradicts one of her findings. I've transcribed that portion:
Reporter: "They were shown various erotic images, and their brain activity monitored."
Prause: "If you think sexual problems are an addiction, we would have expected to see an enhanced response, maybe, to those sexual images. If you think it's a problem of impulsivity, we would have expected to see decreased responses to those sexual images. And the fact that we didn't see any of those relationships suggests that there's not great support for looking at these problem sexual behaviors as an addiction."
The written story under the TV window has a section on the UCLA press release that says essentially the same thing:
"'If they indeed suffer from hypersexuality, or sexual addiction, their brain response to visual sexual stimuli could be expected to be higher, in much the same way that the brains of cocaine addicts have been shown to react to images of the drug in other studies,' a UCLA press release on the study explained.
And yet, that did not happen."
But it did happen! The study DID show a much higher amplitude P300 for the erotic images, compared to the other images. So what Prause says in the interview doesn't match the study results.

 Update two

 A peer-reviewed rebuttal of the Prause paper.

Two more articles taking a look at the SPAN Lab study: 

 Readers may also be interested in our critique of a related SPAN Lab effort using some of the same subjects: No Evidence of Emotion Dysregulation in “Hypersexuals” Reporting Their Emotions to a Sexual Film.