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

LINK TO HER POST



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.
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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

The Rory Reid So-called Critique of Steele et al., 2013 - and Our Response


NOTE: Why have we written a response to a blog post claimed to be written by Nicole Prause's UCLA colleague, Rory Reid. The blog post alos claims to be a "critique" of Prause's July 2013 EEG study,  (Sexual Desire, not Hypersexuality, is Related to Neurophysiological Responses Elicited by Sexual Images). Instead, it is a veiled defense of the Prause EEG study. One give away is that Reid mentions Gary Wilson ten times in his "critique". Another give away is that Rory Reid states 3 times that Gary Wilson's Psychology Today post analyzing Prause's study is no longer published. Both Reid and Prause know very well why it's missing: Prause pressured Psychology Today to remove not only Wilson's post, but this post by two other bloggers. Reid's critique fails to address any of our major points, or explain away Prause's misrepresentations to the press. Instead, Reid deflects criticism by mischaracterizing what my analysis actually said.

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Critique of Prause Study

By Rory C. Reid, Ph.D., LCSW
Assistant Professor Research Psychologist, UCLA Resnick Neuropsychiatric Hospital, Department of Psychiatry, University of California, Los Angeles

There has been a lot of media attention to a recent study conducted by Dr. Nicole Prause and her colleagues titled “Sexual desire, not hypersexuality, is related to neurophysiological responses elicited by sexual images” published in Journal of Socioaffective Neuroscience & Psychology.  My mailbox has been flooded with inquiries from colleagues, patients, and media about my reaction to this study. I’ve responded to some media requests such as Time Magazine to provide a balanced perspective. First, let me say that Dr. Prause is a credible researcher and her office is right next to mine here at UCLA. We have things we agree on and certainly have had our differences which we respectfully debate with each other on a regular basis. One of my initial reactions to this paper is that we should be thanking her for raising the bar on the debates around the phenomenon of hypersexual behavior. While most of my colleagues know I don’t advocate an “addiction” model per se for hypersexuality, this is merely based on scientific evidence which I believe is lacking to characterize it as such at the present time. I have published this position with colleagues elsewhere for review (Kor, Fogel, Reid, & Potenza, 2013). I also work with patients seeking help for hypersexual behavior and many of these individuals perceive themselves as having an “addiction” and I don’t discount their beliefs in therapy based on scientific nomenclature. Although Dr. Prause and I have both been trained in the scientist practitioner model, she is more of a scientist and does not currently see patients although she is qualified to do so and taught doctoral practica on the topic in the past. Subsequently, she is looking at this issue through the lens of a scientist and using scientific methods to investigate sexually dysregulated behavior. I suspect Dr. Prause would acknowledge there are individuals who struggle with regulating their pornography consumption or the frequency of their sexual behavior with partners, commercial sex workers, and so forth; in fact, she seems to be acknowledging exactly this in all her media appearances. However, she would diverge from a common position that such patterns of behavior should be characterized as a “disease” or “addiction” without scientific evidence. So her recent study is challenging the validity of an addiction model or a theory of addiction to explain this phenomenon of sexually dysregulated behavior. An extension of her study would raise a larger question for debate: what is an addiction? This is all very important to understand given her present study at its foundation does not address the issue of whether individuals seeking help for sex addiction, hypersexuality, etc… are experiencing a legitimate problem. It asks whether an addiction theory is the best explanation for this problem or whether there are alternative explanations that help us better understand this phenomenon. That’s it! Somewhere in the mix up, the media has taken this and distorted it to suggest Dr. Prause’s study discounts the existence of sexual problems when it might have been more accurately described as a study challenging addiction as a theory to best explain what is happening with individuals who experience sexually dysregulated behavior.

There are of course, other relevant points to be made. The first is whether a brain marker of any kind (e.g. P3, BOLD activation in fMRI studies, etc…) can or should be consider evidence for the presence or absence of a disorder. This is a significant assumption in many imaging studies that is often overlooked, yet, it’s at the heart of how we might explain and interpret results of science utilizing measures of EEG, fMRI, DTI, and so forth. Keep in mind however, that this also works both ways. We have to be careful suggesting that imaging studies “prove” that hypersexuality or sexual addiction is a legitimate disorder.

Some critiques and commentaries have emerged on the internet on sites like Psychology Today (e.g., Mr. Gary Wilson; Dr. Brian Mustanski). As I’ve looked at some of the critques, I quite frankly disagree with some of them and think they are inaccurate. I’ll address a few of these and then go on to make some points I think we should raise in response to Prause’s study. [Note: Mr. Wilson's posting on Psychology Today has since been removed]

Mr. Wilson has attempted to assert that Dr. Prause has failed to sufficiently analyze an SDI subscale used in her study. Mr. Wilson has erroneously missed information in her article. The Solitary SDI subscore was computed, analyzed, and reported alongside the Dyadic Scale as described in the paper. The paper states “Both are investigated,…” and “Effects that did not reach statistical significance, defined as p < 0.05, are not discussed.” The Solitary scale was not related to the P3. The Dyadic subscale is far more commonly used in the literature and thought to be less subject to reporting bias (“I cannot wait to go home and masturbate” is not as acceptable as “I cannot wait to find an attractive person to have hot sex with”.) The data were fully represented from a widely-used, well-characterized scale. I’m sure Dr. Prause and her colleagues would share their non-significant finding values if anyone requested that data, however, nonsignificant values are often omitted from scientific papers. While they used three different measures of hypersexual problems, they acknowledge in their paper “Although several scales were analyzed in this study to increase the likelihood of identifying a scale that would be related to P300 variance, more scales exist (e.g. Reid, Garos, & Carpenter, 2011) that might better include the proposed core feature of high sexual drive.” For example, the Sexual Compulsivity Scale (SCS) might have been under endorsed by participants who were recruited for “problems regulating their viewing of sexual images” if they did not also feel out of control regarding their relational sexual behavior.

Since the SCS has items related to relational sexual behavior, such items may not have been endorsed lowering scores on the SCS and may have possibly influenced results. This is one of the reasons why my research team developed the Hypersexual Behavior Inventory (Reid, Garos, & Carpenter, 2011) to overcome this limitation. Interestingly, Dr. Prause argues that her method of recruitment “appears to have successfully recruited participants with scores comparable to those labeled as ‘patients’ with hypersexual problems” citing Winters, Christoff, & Gorzalka, 2010 as a comparison. However, I’ve also indicated on other occasions that Winter’s method of classifying hypersexual patients fell short of what we might use in clinical practice. Moreover, I looked at the data from our DSM-5 field trial (one of the only studies published where a diagnostic interview based on the proposed hypersexual disorder criteria was to classify patients as ‘hypersexual’) and ran the descriptive statistics for our SCS data. These numbers were not part of our publication on the DSM-5 field trial (Reid, et al, 2012), but the SCS data for patients in our study yielded means (Mean = 29.2, SD = 7.7) that would be considered statistically significantly higher than the participants SCS scores in Prause’s study (Mean = 22.31, SD = 6.05). Subsequently, I would raise the issue that Prause’s sample does not parallel patients we normally see in treatment and she does appear to also acknowledge this in her paper where she concedes that samples may have differed from treatment seeking ‘sex addicts’ in other ways. In fairness to Dr. Prause, the proposed DSM-5 criteria for hypersexual disorder were not available to her at the time of her data collection.

Some have criticized the analysis, again, appearing to misunderstand statistics tests. In their study, the tests were regressions, not correlations. Correlations were titled “exploratory” in the article to investigate possible relationships that might have been missed with the regressions. These tests assume error in different terms, so are complementary, but different. For some reason, the main finding in the regression analysis is never described in any of the critiques by Mr. Wilson or others. The paper consistently describes these as “relationships” appropriately so these critiques aren’t particularly helpful and suggest Mr. Wilson misunderstands these statistical tests.

Some of the internet critiques mentioned above have also misrepresented how science works. Ideally, a theory is presented, and falsifiable predictions are made from that theory. The addiction model is consistent with an enhanced P3, whereas high sexual desire alone is not. It is, therefore, important that the results of those constructs were different. So, yes, the high sexual desire and the addiction models make different predictions, which allowed an examination of their separable effects.

Some have criticized the participants recruited in this study. They were apparently recruited as described in the study, stratified across scores on several measures of hypersexuality that have been used (and instruments such as the Sexually Compulsivity Scale which I have also used in my own early research in the field). This stratification allows for appropriate distribution of scores necessary for a valid analysis and is a common practice in research. The participants were required to report attraction to the opposite sex. I’m assuming that Dr. Prause did this to establish that the stimuli presented could be argued as relevant for all participants in the study.

One point I might debate with Dr. Prause on this is the degree to which the standardized sexual stimuli used elicited sufficient sexual response, and thus in turn, influenced variance in P3 data. For example, it’s plausible that although sexual arousal was elicited by the sexual stimuli, we have no way of knowing how it might have differed if more explicit, more intense, or stimuli that better mapped to personal preferences were used instead. This issue is discussed at length among sex researchers and is actually very complex. Certainly a replication study using personal preferenced sexual stimuli could be conducted to see if the results remained the same. Prause would likely respond by stating that the stimuli have been used in hundreds of neuroscience studies and were extremely tightly controlled. She’d also likely state that speculations about the necessity of erotica matching specific preferences seems to rest on the assumption that these would be more arousing. She’d further argue that is indeed what was represented in the stimuli: lower and higher intensity sexual stimuli were presented. Visual sexual stimuli ratings were known, characterized, and have been published elsewhere already. This being said, she can’t discount the possibility that specific preference stimuli of a hypersexual population may have some caveats and it’s a future research question to determine if this would make a difference. She appears to acknowledge this since in her paper and interviews with the media she states that the study does need to be replicated.

One important issue that Dr. Prause did not report in her study was whether these patients were assessed for other comorbid psychopathology (e.g., ADHD), history of head trauma, medications, etc… that might have impacted P3 scores. I see this is a possible limitation in her findings. Not screening for such concerns has the advantage of testing a group that might look more like real patients, who we certainly do not refuse help on the basis of these, but has the disadvantage of possible affecting the P300. For example, P300 is affected to positive stimuli in depression, and we do not have depression diagnoses for her participants. A few critique’s suggesting some of Prause’s participants had “no problems” are likely inaccurate. She reported score values (see Table 2 in the paper). Variation in the level of problems is necessary for conducting regressions, which make assumptions such as Gaussian distributions. She also tried to cover her basis using three measures to capture “hypersexuality.” It is difficult to claim all three have no utility. Again, I would argue, as noted above that SCS scores fall short of reflecting a patient population.

I’ve noticed some people mention Prause had no control group. Not sure this is a valid concern. She used a “within-subject” design and while old-school science might make people believe a separate group is necessary in a regression analysis, using a person as their own control, as occurs in a within-subject design, is actually is a stronger statistical approach. Control groups would be more appropriate for a longitudinal study such as whether pornography consumption is harmful. So, we can’t fault her for issues with “control group” or argue that this approach was insufficient to address her research question. However, it might be argued that the within-subject control that they use is insufficient to make between-subject designs could answer other questions.

Criticisms of the cue-reactivity research protocols are likely not valid. I suspect they were likely precisely followed. Prause is very particular in this regard with her research. In substance abuse, eating, and gambling studies, people are presented with pictures of the objects they are struggling with and are not able to interact with them. Similarly, participants in her study were instructed not to masturbate or advance the images in the present study. There are thousands of cue-reactivity studies, many using within-subject designs that resemble the design in her study. It’s an interesting criticism, but without further research, it’s hard to assess if this would really make a substantial difference.

One online critique suggested that the P3 findings presented are conflicting? Not sure why this was concluded. This isn’t true at all. For example, researchers have studied P3 among alcoholics to alcohol cues and to errors on a task. These are entirely different phenomena and are completely misrepresented in the critique. It’s equivalent to calling “EEG” a measure of anything and suggests a lack of fundamental knowledge of EEG and neuroscience. Consider how Prause analyzed her data. First, the replication of the general P3 to emotional stimuli is shown. This has been shown thousands of times and is merely noted as replicated. “Given that this replicated expected, previous findings, the next planned test was conducted.” Then, the relationship with sexual desire is examined, which has been studied before by others. Finally, the relationships with sexual problem measures are examined. As she has stated in her interviews, there was no relationship between the P3 measure and the measures of sexual problems. The study shows a very nice result linking P3 to erotic stimulus responses over other stimuli, but we don’t know whether the relationship between P3 and the behavioral measures is indirect through other variables not measured in her study which could potentially offer alternative explanations for her findings.

One issue I might raise is my discomfort with Mr. Wilson’s dismissal of EEG as a technology. EEG is still used in numerous laboratories across the world, and in some cases concurrently with fMRI. It’s not that EEG doesn’t have its limitations as noted by others (Polich, 2007), but they aren’t the ones mentioned by Mr. Wilson in the context of Prause’s study. A fair criticism might be that EEG is ideal for finding early, fast differences in brain response, where fMRI is ideal for finding where slower differences occur. Neither EEG nor fMRI is inherently a “best” measure. Again, however, as I noted at the beginning of this critique, it is questionable whether brain markers of any kind can or should be consider evidence for the presence or absence of a disorder.

Dr. Don Hilton, in a SASH ListSrv posting raises questions about the nuances of P3 but I think his stronger argument lies in how constructs such as “desire” and “craving” are operationalized and whether such operationalizations are a good proxy for the latent variable of interest.

Conclusions

So, in summary, I think the salient points are as follows:
  • Prause’s study attempts to ascertain whether a theory of addiction has explanatory power in predicting hypersexual behavior over high sexual desire alone. It doesn’t address whether the phenomena of sexually dysregulated behavior is legitimate, only whether an addiction model offers a plausible explanation for such behavior.
  • Prause makes a meaningful contribution to the literature insofar as she’s starting to tackle questions related to a possible cohesive theory to characterize dysregulated sexual behavior. The sex addiction field and even my own work on hypersexual behavior has largely failed to contribute to a theoretical model of dysregulated sexual behavior. Some of the limitations of Prause’s study are a direct result of our own limitations to actually define a testable theory of dysregulated sexual behavior whether it be an addiction model or some other model. Interestingly, no one has asked Dr. Prause if she has her own hypothesis of a model or whether she’s simply going to continue to focus her efforts on falsifying other models.
  • Her study assumes that her measures of desire and hypersexuality capture the latent variable she is studying. Although this is an assumption inherent in many studies including my own, we must remind ourselves that it is, nevertheless, an assumption.
  • EEG is best for finding fast, early differences in brain activity, whereas other imaging techniques offering more detail about where differences happen. These other imaging approaches might bolster arguments for or against an addiction theory. Regardless, replication studies are necessary to provide further support of Prause’s position, as from her study “As ever, these results warrant replication with different participants and protocols more focused on external validity.”
  • Questions about the sample of the participants in used in the study have some merit. Prause attempted to recruit patients, but was prevented from doing so by her local IRB. Any future replication studies should consider using the methods to classify hypersexual patients as per the methods in the DSM-5 field trial for hypersexual disorder. Future studies might also consider investigating concerns about the given study and specific preference stimuli of a hypersexual population. Future studies will also need to control for relevant comorbidity, psychopathology, history of head trauma, and medication effects, although it is still difficult to know which are more important to control and the trade-off is external validity.
  • The media has misconstrued some of Prause’s findings. While she has some responsible to ensure the accuracy of such reports, many of us can relate to the media misquoting or erroneously reporting things we’ve said and should take this into consideration as we read reports about this study.
Note: Mr. Wilson’s page on Psychology Today has been removed. Psychology Today will remove information from their website pages when it’s considered erroneous, inappropriate, or in violation of copyright. There were certainly a substantial amount of errors in Mr. Wilson’s work so perhaps someone at Psychology Today elected to remove it.

References
Kor, A., Fogel, Y. A., Reid, R. C., & Potenza, M. N. (2013). Should hypersexual disorder be classified as an addiction? Sexual Addiction & Compulsivity, 20(1-2), 27–47.
Polich, J. (2007). Updating P300: An integrative theory of P3a and P3b. Clinical Neurophysiology. 118(10), 2128-2148.
Reid, R. C., Garos, S., & Carpenter, B. N. (2011). Reliability, validity, and psychometric development of the Hypersexual Behavior Inventory in an outpatient sample of men. Sexual Addiction &
Compulsivity, 18(1), 30–51. Reid, R. C., Carpenter, B. N., Hook, J. N., Garos, S., Manning, J. C., Gilliland, R., Cooper, E. B., McKittrick, H., Davtian, M., & Fong, T. (2012) Report of findings in a DSM-5 Field Trial for
Hypersexual Disorder. Journal of Sexual Medicine, 9(11), 2868-2877. Winters, J., Christoff, K., & Gorzalka, B. B. (2010). Dysregulated sexuality and high scexual desire: Distinct constructs? Archives of Sexual Behavior, 39(5), 1029-1043.

===============================================


Our Response to Rory 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 most of  the points we raised have been ignored, or spun to have a different meaning, we'd like Dr. Reid to ask Dr. Prause to answer the following additional questions:

1) Why did you spin that your findings indicated hypersexuality was really "high" desire" when your study found greater brain activation correlated with low sexual desire?  Note Prause's wording in this interview:
What is the main finding in your study?
"We found that the brain’s response to sexual pictures was not predicted by any of three different questionnaire measures of hypersexuality. 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 a high libido."
But that didn't happen, as John Johnson PhD explained in this peer-reviewed rebuttal:
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
2) Dr. Prause, why did you mention a "within-subject" control group when nowhere in your EEG study is there a comparison between any two groups?

3) Dr. Prause, why did you make unsupported claims in your Psychology Today interview and elsewhere? The Psychology Today interview:
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.
Does this prove sex addiction is a myth?
If our study is replicated, these findings would represent a major challenge to existing theories of sex “addiction”. 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.
The above claims that subjects brains did not "respond like other addicts is without support. In Steele et al. subjects had higher EEG (P300) readings when viewing sexual images - which is exactly what occurs when addicts view images related to their addiction (as in this study on cocaine addicts). Commenting under the Psychology Today interview of Prause, senior psychology professor emeritus 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."
4) Dr, Prause, what was the correlation between the EEG data and all 14 questions on the Sexual Desire Inventory (SDI)? I'll answer: there was no significant correlation. The study duly reports the solo-sex desire figures, but has this conclusion:
Conclusion: Implications for understanding hypersexuality as high desire, rather than disordered, are discussed.
 Why is the world would you claim "high desire" when subjects with greater cue-reactivity had lower desire for sex with a partner. In addition, the phrase "sexual desire" is repeated 63 times in the study, and the study's title (Sexual Desire, Not Hypersexuality....) implies that higher brain activation to cues was associated with higher sexual desire. Moreover, all the headlines shouted that "sex addiction" was really high desire? But it wasn't high desire!

5) 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.

6) Dr, Prause, where is the evidence that "dyadic interest alone" is commonly used as a measure of "sexual desire?" You keep 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."

7) Dr. Prause, surely you know standard protocol for an addiction study assessing cue-induced brain activity. Why then were the subjects men and women, including 7 non-heterosexuals? Study after study confirms that men and women have significantly different brain responses to sexual images or films. Valid addiction brain studies involve homogenous subjects: same sex, same sexual orientation, along with similar ages and IQ's. This alone discounts your findings.

8) Dr. Prause, how can your justify non-heterosexuals in an experiment with only heterosexual porn - and then draw vast conclusions from a (predictable) lack of correlation? This also calls your results into question.

9) Dr. Prause, why were your subjects not pre-screened? Valid addiction brain studies screen individuals for pre-existing conditions (depression, OCD, other addictions, etc.). This also calls your results into question.

10) Dr. Prause, why did you use the SCS (Sexual Compulsivity Scale) when it isn't a valid assessment test for Internet-porn addiction or for women? It was created in 1995 and designed with uncontrolled sexual relations in mind (in connection with investigating the AIDS epidemic). Again, this alone explains why there were no correlations between P300 readings and the SCS.

Back to the Sexual Desire Inventory (SDI), and Rory Reid's claim 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. While Steele et al reported a negative correlation between EEG readings and the partnered SDI questions, this finding manifested itself as a misleading study title and false headlines about "sexual desire". The actual results from the study:
"Larger P300 amplitude differences to pleasant sexual stimuli, relative to neutral stimuli, was negatively related to measures of sexual desire, but not related to measures of hypersexuality."
Translation: Individuals with greater cue-reactivity to porn had lower desire to have sex with a partner (but not lower desire to masturbate). To put another way - individuals with more brain activation and cravings for porn would rather masturbate to porn than have sex with a real person. Quite different from the interviews and headlines.

Have a look at Table 2 from the full text of the study.

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 addiction," no daring media blitz, and no need for all the behind-the-scenes intimidation to try to shore up a flawed finding. In short, Steele et al. findings of little correlation between EEG readings and questionnaires 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 summaries of 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. 

UPDATE 2 - January, 2015: Nicole Prause is no longer employed by UCLA

UPDATE 3 - There are now 4 peer-reviewed analysis of Steele et al. All agree with our critique. Paper #1 is solely devoted to Steele et al. Papers 2 & 3 contain sections analyzing Steele et al.
UPDATE 4 (2015): Prause appears to profit from denying sex and porn addiction
Finally, it should be noted that Nicole Prause now offers her "expert" testimony against "sex addiction". From her Liberos website (page since removed):

“Sex addiction” is increasingly being used as a defense in legal proceedings, but its scientific status is poor. We have provided expert testimony to describe the current state of the science and acted as legal consultants to help teams understand the current state of the science in this area to successfully represent their client.
Legal consultations and testimony are generally are [sic] billed on an hourly rate.

_________________________________________

Nicole Prause begins Her campaign of Harassment

March 5, 2013
Author of “The Myth of Sex Addiction,” David Ley, and Nicole Prause team up to write a Psychology Today blog post with the strategic title: "Your Brain on Porn - It's NOT Addictive." (Your Brain On Porn is a website founded by Wilson.) It was about Nicole Prause's unpublished, yet to be peer-reviewed EEG study ("Sexual desire, not hypersexuality, is related to neurophysiological responses elicited by sexual images").

It’s important to note that only Ley received access to Prause's unpublished study (it was published 5 months later). The blog post linked to Wilson's 'Your Brain on Porn' website and suggested that YBOP was in favor of banning porn (untrue).
  • Key point: Five months before Prause’s EEG study (Steele et al., 2013) was published, both Prause and Ley were targeting Gary Wilson and his website.
March 7, 2013
Wilson published a Psychology Today blog post responding to the content in the David Ley post. Ley's blog post and Wilson’s response were eventually removed by Psychology Today editors, as the underlying study wasn't yet available. You can find the original Ley and Wilson blog posts archived here. It's important to note that Wilson’s blog post clearly states it was only responding to Ley's description of the Prause study. Later Nicole Prause would falsely accuse Wilson of misrepresenting her study (that only she and Ley had seen, and were making public claims about - which were later shown to be unfounded).

March 7, 2013
Wilson posts under David Ley's article requesting the study:
"Hey David - I'm wondering how you got your hands on a study that has yet to published, or mentioned anywhere else. Are you willing to send me a copy?"
David Ley did not respond.

April 10, 2013
In response to the above comment, Prause contacted the Psychology Today editors and emailed Wilson the following. In the email, Prause attacks Wilson personally, and mistakenly states that he did not ask for the study. He had, in fact, asked David Ley for it. The email:
Psychology Today (no-reply@psychologytoday.com)
4/10/13
To: _______@hotmail.com
From: Nicole Prause <nprause@________>
Dear Mr. Wilson,
It is illegal for you to misrepresent our science having never even requested a copy of the manuscript. It will be treated as such. Our article actually is very balanced. Unlike you, I have peer-reviewed publications on both sides of this issue. You have attempted to discredit it by describing things that were not done. I am pursuing this with Psychology Today now, but I would advise  you to remove the post yourself before I am forced to pursue further action.

You also do not have permission to quote any portion of this email. It is private communication.

Sell your books on your own merit. Don't try to make money off the backs of scientists doing their jobs. I can tell this study clearly panics you because  the design and data are strong, but it is egregious to have not even asked  for a copy of the manuscript and just make up content. Shame on you.
Nicole Prause, PhD
Research faculty
UCLA
In addition, Psychology Today editors forwarded a second email from Prause:
Date: April 10, 2013 5:13:30 PM EDT
Topic: Comment on the Blogs
From: Nicole Prause, PhD <nprause@_____________
To whom it may concern:
I was surprised to see an article written about a study of mine by Gary Wilson on Psychology Today.
I have no problem with him representing his own views and interpretations of studies, but he does not and could not have had access to mine. It is under review and he never requested a copy from any of the authors. I notified him that it should be removed. He has not yet done so. Of course, once it is public record, he will have access to it and be able to represent it (hopefully) more accurately.
Of course, knowingly misrepresenting a person to denigrate them is illegal. I hope Psychology Today will take this matter seriously. I will contact other board members as well, in case your cue is full and may take longer to respond.
Thank you for your help in resolving this matter.
sincerely,
Nicole Prause, PhD
The groundless legal threats, false claims, and playing the victim begin in her very first contact with Wilson. Nothing Prause says is true:
  1. Wilson did not describe Prause's study or misrepresent it in any way. He only responded to Ley's description of the study. Read Ley's and Wilson's blog posts and judge for yourself.
  2. To this day Prause has yet to refute a single word in Wilson’s March, 2013 Psychology Today post, or the analysis Wilson wrote in July after her EEG study finally was published. Nor has Prause refuted a single word in four peer-reviewed critiques of her 2013 EEG study (1, 2, 3, 4.).
  3. Wilson makes no money off of this endeavor.
  4. Wilson asked for a copy of the study (Prause refused to supply it).
  5. Prause initiated all contact with Wilson.
Wilson's email response to Nicole Prause:

On Wed, Apr 10, 2013 at 3:14 PM, gary wilson <> wrote:

Hi Nicole,
I commented under your comment. Have a look.
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


April 12, 2013
Two days later Prause contacted Wilson again threatening further legal action. She somehow tracked down one of Wilson's comments on the porn-recovery site Your Brain Rebalanced. It was posted on a long thread about David Ley's original blog post. Wilson’s comment was meant to explain why both Ley’s and Wilson’s Psychology Today posts had been removed by Psychology Today. This signaled Prause’s pattern of cyberstalking, as a not even a Google search could locate that post. How did Prause know about this thread on a porn recovery forum?

The Prause email:
Nicole Prause (nprause@_______)
4/12/13
Dear Mr. Wilson,
In your post: http://yourbrainrebalanced.com/index.php?topic=7522.50
You falsely claim: "I responded to her rather nasty emails with a request to see her study, and she refused."
This is libel. Please remove this post or I will follow up with legal action.
Nicole Prause
Wilson responds:
On Fri, Apr 12, 2013 at 11:09 AM, gary wilson <> 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?
Best,
Gary Wilson
Prause emails again with more crazy claims & legal threats [Note: Neither Wilson nor his wife ever initiated contact with Prause. She is the one who repeatedly contacted them and threatened them with groundless legal action.]
From: nprause@_________ Date: Fri, 12 Apr 2013 15:01:09 -0700
Subject: Re: [PT] Inquiry via Psychology Today
Dear Gary,
This is to notify both you and your wife that your (both you and your wife's) contact is unwanted. Per stalking statutes in your home state (http://courts.oregon.gov/Lane/Restraining.page), any additional harassing contact will be interpreted as actionable harassment.
You do not have my permission to share this private communication in any forum.
Nicole Prause
Wilson sends his final email to Prause, to set the record straight: that she is the one initiating all contact and the only person making threats (and false claims):
From: ______@hotmail.com
To: nprause 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
The end of the beginning with Nicole Prause.

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The harassment of Gary Wilson and others continues to this day. See this page for extensive documentation of Nicole Prause's behavior (including Prause's personal attacks on former UCLA colleague Rory Reid)