Sunday, January 10, 2016

Critique of "Perceived Addiction to Internet Pornography and Psychological Distress: Examining Relationships Concurrently and Over Time" (2015)

 A lost has occurred since Grubbs published this study. See the following critiques and studies that expose the Grubbs CPUI-9 and so-called "perceived porn addiction" for they are - an agenda driven scam:

  1. Research Suggests the Grubbs, Perry, Wilt, Reid Review is Disingenuous ("Pornography Problems Due to Moral Incongruence: An Integrative Model with a Systematic Review and Meta-Analysis") 2018
  2. Is Joshua Grubbs pulling the wool over our eyes with his "perceived porn addiction" research? (2016)
  3. New study invalidates the Grubbs CPUI-9 as an instrument to assess either “perceived pornography addiction” or actual pornography addiction (2017)
  4. Religious People Use Less Porn and Are No More Likely to Believe They Are Addicted (2017)
  5. Critique of: "Damaged Goods: Perception of Pornography Addiction as a Mediator Between Religiosity and Relationship Anxiety Surrounding Pornography Use" (Leonhardt, Willoughby, & Young-Petersen, 2017)
  6. Is Utah #1 in Porn Use?

Here are a few of the headlines birthed from this new study  by Joshua B. Grubbs, Nicholas Stauner, Julie J. Exline, Kenneth I. Pargament, and Matthew J. Lindberg (Grubbs et al.):
  • Watching Porn Is OK. Believing In Porn Addiction Is Not
  • Perceived Addiction To Porn Is More Harmful Than Porn Use Itself
  • Believing You Have Porn Addiction Is the Cause of Your Porn Problem, Study Finds
In essence the study's main claim is reported as: "perceived addiction" to pornography is more related to psychological distress than are current daily hours of porn viewing. An excerpt from one of the above articles:

A new study in the journal Psychology of Addictive Behaviors has found that perceived addiction to pornography—that is, “feeling addicted to Internet pornography irrespective of actual pornography use”—is associated with forms of psychological distress including depression, anxiety, anger, and stress. Pornography use itself, the authors found, was “relatively unrelated to psychological distress.” 

 While the above quote contains inaccuracies which we will explore, let's take it at face value. The reader is left with the impression that actual porn use is no big deal, but "believing" you are addicted to porn will cause you psychological distress. The take away: It's perfectly healthy to use porn as long as you don't believe you are addicted.

Grubbs et al.'s claim, and all the resulting headlines, are built upon this finding: Subjects' current hours of porn use did not correlate strongly enough (in researchers' subjective view) with scores on Grubbs's own porn use questionnaire (the Cyber Pornography Use Inventory "CPUI"). To put it another way, if porn addiction really existed there "should" be, in the authors' view, a one-to-one relationship between current hours of use and scores on the CPUI. Grubbs et al. also reported that "psychological distress" was related to scores on the CPUI, but not as strongly related to current hours of use.

Here's the thing: There's absolutely no scientific basis for declaring the CPUI a measure of "perceived addiction," and yet that's what all the inflated headlines rest on! The CPUI was never validated for "perceived" as opposed to "real" addiction.

For Grubbs et al.'s claims and interpretations to be valid, BOTH of the following must be true and supported by actual research:

1) The Cyber Pornography Use Inventory (CPUI) must assess "perceived addiction" to porn but not actual porn addiction.
  • Grubbs himself developed the 9-item CPUI as an inventory of online porn problems, not a "perceived addiction" test. Here he chose to use it in lieu of other validated addiction tests, precisely to create the illusion that he could measure "perceived addiction" rather than addiction. In fact, the CPUI measures the same signs, symptoms and indications of addiction as do standard addiction tests.
  • In the current study, Grubbs et al. use the phrase "perceived porn addiction" synonymously with subjects' scores on the CPUI, without scientific justification.
2) Internet porn addiction must equal hours of porn viewing.
  • This is refuted by the scientific literature. Internet porn addiction ≠ hours of porn viewing.
  • Shockingly, the Grubbs et al. study reveals there actually was a strong correlation between hours of use and the CPUI! From p. 6 of the study:
"Additionally, average daily pornography use in hours was significantly and positively associated with depression, anxiety, and anger, as well as with perceived addiction."
With respect to the first point, Grubbs developed his own porn addiction questionnaire (CPUI), and then later capriciously declared that it measures only "perceived addiction to porn" - without demonstrating any justification for his recharacterization. (Really!)

With respect to the second point, previous research teams have found that the variable "hours of use" is not correlated with cybersex addiction (or video-gaming addiction). That is, addiction is more accurately predicted by other variables than "hours of use." As you can see from the above excerpt, Grubbs actually found a significant correlation between hours of use and psychological distress.

We'll look at details about why Grubbs et al.'s assumptions are neither true nor supportable below, but here's how the researchers could have described their actual findings without misleading the public:

"Study finds that porn addiction is strongly related to psychological distress and less strongly (but still) related to current hours of use."

The cliff notes version: Addiction is related to psychological distress, and so are hours of use. So much for the attention-grabbing, misleading headlines spawned by the study.


The CPUI Assesses Porn Addiction, Not "Perceived Addiction"


This is really simple: Grubbs et al. relabeled Grubbs's self-created porn addiction test as a "perceived porn addiction" test. However, his Cyber Pornography Use Inventory (CPUI) questionnaire is in fact similar to many other drug and behavioral addiction questionnaires. Like other addiction tests, the CPUI assesses behaviors and symptoms common to all addictions, such as: the inability to control use; compulsion to use, cravings to use, negative psychological, social and emotional effects; and preoccupation with using. In fact, only 1 of the 9 questions below even hints at "perceived addiction." Yet we are told that a person's total score for all 9 questions is synonymous with "perceived addiction" rather than addiction itself. Very misleading, very clever, and without any scientific basis. Agnotology fodder, anyone? (Agnotology is the study of culturally induced ignorance or doubt, particularly the publication of inaccurate or misleading scientific data.) Reality check: other researchers describe the CPUI as an actual porn addiction assessment questionnaire, and use it as such in their published studies:

Note that decades of established addiction assessment tests for both chemical and behavioral addictions rely on similar questions to assess actual, not merely perceived, addiction. Let's compare the CPUI to a commonly used addiction assessment tool known as the "4 Cs." The CPUI questions that correlate with the four Cs are noted as well.
  • Compulsion to use (2, 3)
  • Inability to Control use (2, 3, maybe 4-6)
  • Cravings to use (3 especially, but 1-6 could be interpreted as cravings)
  • Continued use despite negative consequences (4-6, perhaps 7-9)
The Cyber Pornography Use Inventory (CPUI) (developed by Grubbs)

1. I believe I am addicted to Internet pornography.
2. I feel unable to stop my use of online pornography.
3. Even when I do not want to view pornography online, I feel drawn to it

4. At times, I try to arrange my schedule so that I will be able to be alone in order to view pornography.
5. I have refused to go out with friends or attend certain social functions to have the opportunity to view pornography.
6. I have put off important priorities to view pornography.

7. I feel ashamed after viewing pornography online.
8. I feel depressed after viewing pornography online.
9. I feel sick after viewing pornography online.

Addiction experts rely on assessment tools like the 4Cs as indicating addiction because neuroscientists have correlated the symptoms those questions address with underlying addiction-related brain changes in decades of basic-research studies. As a medical matter, addiction is a disorder of the brain. It shows up in very specific behaviors, but can't be assessed from superficial indications such as hours of use. See the public policy statement of the American Society of Addiction Medicine.

In short, the CPUI does a better job at actually identifying that which it purports to differentially diagnose against (actual addiction) than at identifying "perceived addiction," as Grubbs claims it does.

Finally, we must ask why Grubbs found it necessary to create his own internet porn addiction test. Others, well established and thoroughly validated, were available to him. Might it be that as the author of the CPUI he assumes he has the power to re-label it as a "perceived addiction to porn" test in order to fool readers into believing that all porn addicts are misdiagnosing themselves? Sorry, if it walks like a duck and talks like a duck....

Bottom Line: The CPUI assesses actual porn addiction, not "perceived" porn addiction. Delete the word "perceived" from the study, and every article about it, and you are left with an unsurprising finding: psychological distress is related to perceived porn addiction.

Current Hours of Use Are Not Related To Porn Addiction


Grubbs et al.'s conclusion is largely based on a faulty premise: The extent of a porn addiction is best assessed simply by hours of internet porn viewing. As Grubbs et al. did not find a tight enough correlation (in their view) in their subjects, they concluded their subjects merely had "perceived addiction" instead. Two huge holes in the story render Grubbs et al.' claim highly suspect.

As described earlier, the first gaping hole is that Grubbs et al. actually found a pretty strong correlation between hours of use and the CPUI! From p. 6 of the study:
"Additionally, average daily pornography use in hours was significantly and positively associated with depression, anxiety, and anger, as well as with perceived addiction."
Stop the presses! This excerpt directly contradicts all the headlines, which claim that pornography use was NOT strongly correlated with psychological distress or "perceived addiction." Again, whenever you see the phrase "perceived addiction" it actually denotes the subjects' total score on the CPUI (which is a porn addiction test).

To say all of this another way: Both psychological distress and CPUI scores were significantly correlated with hours of use. Does any journalist or blogger ever read an actual study?

The second hole in this study's underpinnings, which you could drive a truck through, is that research on internet porn and videogame use has established that neither addiction correlates with hours of use. The variable 'hours of use' is an unreliable measure of addiction, and established addiction assessment tools evaluate addiction using multiple other factors (such as those listed in the CPUI). The following cybersex addiction studies, which Grubbs omitted, report little relationship between hours and indications of addiction:

1) Watching Pornographic Pictures on the Internet: Role of Sexual Arousal Ratings and Psychological-Psychiatric Symptoms for Using Internet Sex Sites Excessively (2011)
"Results indicate that self-reported problems in daily life linked to online sexual activities were predicted by subjective sexual arousal ratings of the pornographic material, global severity of psychological symptoms, and the number of sex applications used when being on Internet sex sites in daily life, while the time spent on Internet sex sites (minutes per day) did not significantly contribute to explanation of variance in Internet Addiction Test sex score (IATsex). We see some parallels between cognitive and brain mechanisms potentially contributing to the maintenance of excessive cybersex and those described for individuals with substance dependence."
2) Sexual Excitability and Dysfunctional Coping Determine Cybersex Addiction in Homosexual Males (2015)
Recent findings have demonstrated an association between CyberSex Addiction (CA) severity and indicators of sexual excitability, and that coping by sexual behaviors mediated the relationship between sexual excitability and CA symptoms. Results showed strong correlations between CA symptoms and indicators of sexual arousal and sexual excitability, coping by sexual behaviors, and psychological symptoms. CyberSex Addiction was not associated with offline sexual behaviors and weekly cybersex use time.
3) What Matters: Quantity or Quality of Pornography Use? Psychological and Behavioral Factors of Seeking Treatment for Problematic Pornography Use (2016)
According to our best knowledge this study is the first direct examination of associations between the frequency of porn use and actual behavior of treatment-seeking for problematic porn use (measured as visiting the psychologist, psychiatrist or sexologist for this purpose). Our results indicate that the future studies, and treatment, in this field should focus more on impact of porn use on the life of an individual (quality) rather than its mere frequency (quantity), as the negative symptoms associated with porn use (rather than porn use frequency ) are the most significant predictor of treatment-seeking behavior.
Relation between PU and negative symptoms was significant and mediated by self-reported, subjective religiosity (weak, partial mediation) among non-treatment seekers. Among treatment-seekers religiosity is not related to negative symptoms.
4) Examining Correlates of Problematic Internet Pornography Use Among University Student (2016)
Higher scores on addictive measures of internet porn use were correlated with daily or more frequent use of internet porn. However, the results indicate that there was no direct link between the amount and frequency of an individual’s pornography use and struggles with anxiety, depression, and life and relationship satisfaction. Significant correlations to high internet porn addiction scores included an early first exposure to internet porn, addiction to video games, and being male. While some positive effects of internet porn use have been documented in previous literature our results do not indicate that psychosocial functioning improves with moderate or casual use of  internet porn.
Thus, from the outset this study and its assertions collapse because its conclusions rest upon equating current hours of use with the level of addiction/problems/distress reported by subjects as a valid measure of addiction.

Why don't addiction specialists rely on hours of use? Imagine trying to assess addictions by simply asking, "How many hours do you currently spend eating (food addiction)?" or "How many hours do you spend gambling (gambling addition)?" or "How many hours do you spend drinking (alcoholism)?" To demonstrate how problematic hours of use would be, consider alcohol as an example:
  1. A 45-year old Italian man has a tradition of drinking 2 glasses of wine every night with dinner. His meal is with his extended family and it takes 3 hours to complete (lots of yakking). So he drinks for 3 hours a night, 21 hour per week.
  2. A 25 year-old factory worker only drinks on the weekends, but binge drinks both Friday and Saturday night to the point of passing out or getting sick. He regrets his actions and wants to stop, but can't, drives drunk, gets in fights, is sexually aggressive, etc. He then spends all of Sunday recovering, and feels like crap until Wednesday. However, he spent only 8 hours a week drinking.
Which drinker has a problem? This is why "current hours of use" alone cannot inform us as to who is addicted and who is not.

Finally, we must ask why Grubbs et al. chose to create the CPUI when other, thoroughly validated addiction tests were readily available.

Bottom line: The study's claims depend upon "current hours of use" being a valid criterion for true addiction. They are not. Moreover, once you get past the abstract, the full study reveals that "current hours of use" is actually related to both psychological distress and CPUI scores!

"Current Hours of Use" Omits Many Variables


A secondary methodological problem is that Grubbs et al. assessed porn use by asking subjects about their "current hours of porn use." That question is troublingly vague. Over what period? One subject may be thinking "How much did I use yesterday?" another "over the last week?" or "on average since I decided to quit viewing because of unwanted effects?" The result is data that are not comparable can't be analyzed for the purpose of drawing reliable conclusions.

More important, the "current porn use" question, on which the study's conclusions rest, fails to ask about key variables of porn use: age use began, years of use, whether the user escalated to novel genres of porn or developed unexpected porn fetishes, the ratio of ejaculation with porn to ejaculation without it, amount of sex with a real partner, and so forth. Those questions would likely enlighten us more about who really has a problem with porn use than simply "current hours of use."

Deeper Analysis: Addiction Correlates With Addiction, not Emotional Distress


We have established that the CPUI is in no way a "perceived addiction" test. Instead, the CPUI is an actual porn addiction test assessing 3 categories of compulsive pornography use:
  1. Compulsion to use & Inability to control use
  2. Efforts to use (negative consequences)
  3. Emotional Distress after using (shame, depression, feel sick)
What do the conspicuous headlines claim and the authors assert? That psychological distress about one's porn addiction is the real problem, rather than the addiction itself. If that were true, we would expect "porn addicts" to score especially high in Emotional Distress category of the CPUI. Not so. From p. 9 of the study:
"In all SEM analyses, emotional distress consistently had the weakest loadings on the latent factor of perceived addiction...... Such a consistent pattern across studies strongly indicates that emotional distress regarding use is not the primary driving factor in the link between perceived addiction and psychological distress."
Translation: Scores on the CPUI Emotional Distress section were the least related to scores on separate Psychological Distress questionnaires (which measure such things as stress, depression and anger). Put simply, the psychological distress of porn addiction does NOT arise from shame or guilt. Instead, psychological distress arises from the inability to control use despite negative consequences, as measured by CPUI sections 1 and 2. From pg 9 of the study:
By contrast, perceived compulsivity—the direct acknowledgment of feelings of addiction to pornography—was consistently the primary factor driving perceived addiction. Additionally, access efforts [negative consequences] loaded more strongly on perceived addiction than emotional distress regarding use.
Translation: The inability to control use (questions 1-3) coupled with negative consequences (questions 4-6), was more strongly related to "psychological distress." Put simply, guilt and shame weren't such a big deal, but inability to control use, the compulsion to watch porn when subjects don't want to, refusing to go out with friends or attend social functions in order to view pornography, and putting off important priorities to view pornography, are what really upset subjects.

This is a very different reality than readers got from either the misleading headlines or study abstract.

Grubbs Introduction Distorts Current State of the Research


In the introduction and discussion sections Grubbs et al. toss aside decades of neuropsychological and other addiction research (and related assessment tools) to attempt to persuade readers that the scientific literature shows that internet porn addiction doesn't exist (and that therefore that all evidence of porn addiction must be "perceived," not real). A new review shows just how farfetched this contention is. See Neuroscience of Internet Pornography Addiction: A Review and Update, which aligns decades of addiction neuroscience research with recent neuroscience and neuropsych studies on porn users themselves. It concludes (logically and scientifically) that internet pornography addiction is quite real, and in fact a subset of internet addition (based on more than 100 brain studies, as well as hundreds of other relevant studies).

In their opening paragraphs, Grubbs et al. demonstrate their profound bias by basing their claim about the nonexistence of internet porn addiction on the papers of two self-proclaimed "internet porn addiction debunkers": David Ley, author of The Myth of Sex Addiction, and former UCLA researcher Nicole Prause, whose work has been formally criticized in the medical literature for weak methodology and unsupported conclusions.

For example, Grubbs et al. rely on a one-sided paper by Ley, Prause and their colleague Peter Finn, which claimed to be a review (that is, an impartial analysis of the existing literature). However, it omitted or misrepresented nearly every study that found negative effects of internet porn use, while also ignoring the dozens of recent internet addiction studies demonstrating addiction-related structural brain changes in internet addicts' brains. (Line-by-line critique can be found here.)

Equaling telling is Grubbs et al.'s omission of every brain scan and neuropsychological study that found evidence in support of the porn addiction model (over a dozen collected here). Instead of hard science from the many omitted studies, the reader is given an overreaching conclusion:
In sum, there is a fair amount of evidence suggesting that many individuals feel addicted to Internet pornography, even in the absence of a clinically verified diagnosis to subsume such a disorder.
Finally, the only neurological study cited by Grubbs as refuting porn addiction (Steele et al.) actually supports the porn addiction model. Steele et al. reported higher EEG readings (P300) when subjects were exposed to porn photos. Studies consistently show that an elevated P300 occurs when addicts are exposed to cues (such as images) related to their addiction. In addition, the study reported that greater cue-reactivity to porn correlated with less desire for partnered sex. As neither result matched the headlines, Grubbs perpetuated the flawed conclusions of the original authors (the "debunkers of porn addiction").



Given its unsupported conclusions and biased claims about the non-existence of porn addiction, it seems likely that Grubbs et al. designed this study to meet a specific agenda - to re-label porn addiction as "perceived addiction" and persuade readers that porn use is harmless and they need only worry about believing it can harm. Agnotology mission accomplished!

This saying comes to mind: What the abstract giveth, the full study taketh away. The headlines and claims spawned by Grubbs et al. are not even supported by the underlying study. Again,
  1. Both internet gaming and internet porn addiction studies have already established that hours of use do not correlate well with addiction. This fact alone guts this entire study and its misleading headlines.
  2. The Cyber Pornography Use Inventory (CPUI) assesses the signs, symptoms and behaviors of an addiction, not "perceived addiction". Don't be fooled; the CPUI was never validated for "perceived" as opposed to "real" addiction.
  3. Grubbs et al.'s study reveals that the "average daily pornography use in hours was significantly and positively associated with depression, anxiety, and anger, as well as with perceived addiction (the CPUI)." This directly contradicts the press claims that say hours of use were not related to CPUI scores or psychological distress.
Any one of the above dismantles this study, but all three mean that this study should be ignored as the work of agnotology that it is.

Research such as this contributes to the ongoing campaign to confuse the public about the reality of internet porn addiction. For example, one frequently sees attempts by Grubbs's colleagues to conflate internet porn addiction with sex addiction and then sweep both away as "unsupported," even though the neuropsychological and medical evidence demonstrating internet addiction is already overwhelming. Another tactic is to conflate internet porn addiction with "Hypersexual disorder" and then claim that the DSM-5, by rejecting the latter, has rejected the former. In fact, internet porn addiction was never formally proposed, or evaluated, for inclusion in the DSM-5. It's time it was, given the mounting evidence that both internet addiction and its subtype internet porn addiction are true addictions.

In the same tradition, Grubbs et al., without justification, now attempt to sweep aside decades of addiction research and assessment tests developed for all kinds of addictions, and substitute their own worldview (that internet porn addiction doesn't exist and should be recast as "perceived addiction"). Should society and its headline-hungry journalists allow this? You be the judge.

Sunday, August 30, 2015

Analysis of "Modulation of late positive potentials by sexual images in problem users and controls inconsistent with 'porn addiction' (2015)", by SPAN Lab


Because this paper reported greater porn use related to less brain activation to vanilla porn it is listed as supporting the hypothesis that chronic porn use down regulates sexual arousal. Put simply, the more frequent porn users were bored by static images of ho-hum porn (its findings parallel Kuhn & Gallinat., 2014). These findings are consistent with tolerance, a sign of addiction. Tolerance is defined as a person’s diminished response to a drug or stimulus that is the result of repeated use.
Eight peer-reviewed papers agree with YBOP’s assessment of Prause et al., 2015:
  1. Neuroscience of Internet Pornography Addiction: A Review and Update (2015)
  2. Decreased LPP for sexual images in problematic pornography users may be consistent with addiction models. Everything depends on the model (Commentary on Prause et al., 2015)
  3. Neurobiology of Compulsive Sexual Behavior: Emerging Science (2016)
  4. Should compulsive sexual behavior be considered an addiction? (2016)
  5. Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016)
  6. Conscious and Non-Conscious Measures of Emotion: Do They Vary with Frequency of Pornography Use? (2017)
  7. Neurocognitive mechanisms in compulsive sexual behavior disorder (2018)
  8. Online Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019)
Because frequent porn users had lower EEG readings than controls, lead author Nicole Prause claims her anomalous study falsifies the porn addiction model. Prause proclaimed that her EEG readings assessed “cue-reactivity” (sensitization), rather than habituation. Even if Prause were correct she conveniently ignores the gaping hole in her “falsification” assertion: Even if Prause et al. 2015 had found less cue-reactivity in frequent porn users, 21 other neurological studies have reported cue-reactivity or cravings (sensitization) in compulsive porn users: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21. Science doesn’t go with the lone anomalous study hampered by serious methodological flaws; science goes with the preponderance of evidence (unless you are agenda-driven).

Update: In this 2018 presentation Gary Wilson exposes the truth behind 5 questionable and misleading studies, including the two Nicole Prause EEG studies (Steele et al., 2013 and Prause et al., 2015): Porn Research: Fact or Fiction?

    Hyperbole & Inaccurate Claims


    Let’s start with the lead author’s hyperbole. Nicole Prause, boldly claimed on her SPAN lab website that this solitary study “debunks porn addiction”:

    What researcher would ever claim to debunk an entire field of research and to refute all previous studies with a single study?(Close ties to the industry in question might cloud a researcher’s perceptions).

    In addition, Nicole Prause claimed her study contained 122 subjects (N). In reality, the study had only 55 subjects who were “experiencing problems regulating their viewing of sexual images”. The subjects were recruited from Pocatello Idaho, which is over 50% Mormon. The other 67 participants were controls.

    In another dubious claim, Prause, et al. 2015 stated in both their abstract and in the body of the study:
    These are the first functional physiological data of persons reporting VSS regulation problems“.
    This is clearly not the case, as the Cambridge fMRI study was published nearly a year ago.
    In a third claim Nicole Prause has consistently asserted that Prause et al., 2015 is “the largest neuroscience investigation of porn addiction ever conducted”. It should be noted that compared to brain scan studies, EEG studies are far less expensive per subject. It’s easy to gather a large group of “porn addicted” subjects if you don’t screen the subjects for porn addiction or any exclusionary condition (mental problems, addictions, psychotropic drug use, etc.). A few problems with Prause’s claim:
    1. It’s not a study on porn addiction if it has no porn addicts. This study, and 2 earlier Prause studies (Prause et al., 2013 & Steele et al., 2013) did not assess whether any of the subjects were porn addicts or not. Prause admitted in an interview that many of the subjects had little difficulty controlling use: they were not addicts. All of the subjects would have to have been confirmed porn addicts to permit a legitimate comparison with a group of non-porn addicts. In addition the Prause Studies did not screen subjects for mental disorders, drug use, compulsive behaviors, or other addictions. Three of the five peer-reviewed critiques point out these fatal flaws: 2, 3, 4.
    2. “HPA axis dysregulation in men with hypersexual disorder” (2015) could be considered the largest neuroscience-based study to date on “hypersexuals” (with 67 subjects in treatment for sex addiction, as compared to Prause’s 55 subjects who were upset about their porn use). The study assessed the brain’s response to stress by assessing a hormone release by the brain (ACTH), and a hormone controlled by the brain (cortisol). While this study was a published a few months after Prause et al., 2015, Nicole Prause continues to claim her EEG study as the largest.
    3. Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn (2014) – Could be considered larger than Prause et al., 2015, because it had 64 subjects, and all were carefully screened for exclusionary items such as addictions, substance use, mental disorders, and medical & neurological disorders. The 3 Prause studies did not do this.

    Prause, et al Assessed Brain Wave Activity


    Prause, et al. was an Electroencephalography or EEG study. EEG's measure electrical activity, or brain waves, on the scalp. Although EEG technology has been around for 100 years, debate continues as to what actually causes brain waves, or what specific EEG readings really signify. As a consequence, experimental results may be interpreted in a variety of ways. Spikes in electrical activity are called amplitudes (below).

    Researchers believe that certain EEG amplitudes (LPP, P3) may assess attention given to a particular stimulus, such as a picture. Put simply, greater amplitudes indicate the subject is paying greater attention to the visual stimulus presented in the experiment. In the Prause study the stimulus was a one-second exposure to a sexual photo. A few important points:
    1. Greater attention, and the corresponding EEG spike, cannot tell us if the person was sexually aroused or if they were repulsed. A higher spike may just as easily be caused by negative emotions, such as disgust or shock.
    2. Nor can an EEG spike tell us if the brain's reward circuitry was activated or not. In contrast, other recent studies on porn users by Voon et al. and Kuhn & Gallinat used fMRI scanners to pinpoint structural changes and reward circuit activity.
    In this study, Prause et al. compared the EEG activity of so called "porn addicts" (average 3.8 hours of porn/week) to controls (average 0.6 hours of porn/week). As expected, both "porn addicts" and controls had greater EEG activity (LPP amplitude) when viewing sexual photos. However, the amplitude was smaller for the "porn addicts."

    Prause et al. Actually Supports Porn Addiction


    Expecting a greater amplitude for "porn addicts", the authors stated, "This pattern appears different from substance addiction models." But does that really make sense?

    As a researcher friend says, in any study there are results...and there are the researcher's interpretations. The results are pretty clear: Porn addicts paid less attention to photos of vanilla sex flashed on the screen for one second. This is no surprise to anyone who overconsumes today's porn.

    Prause's findings of lower LPP amplitudes for "porn addicts" when compared to controls actually aligns with the addiction model, notwithstanding her interpretation that she has "debunked porn addiction." Her finding indicates both desensitization (or habituation) and tolerance, which is the need for greater stimulation. Both are commonly seen in addicts, and, somewhat alarmingly, have also been recorded in heavy porn users who were not addicts (more below).

    Key point: If porn use had no effect on Prause's subjects, we would expect controls and "porn addicts" to have the same LPP amplitude in response to sexual photos. Instead, Prause's so-called "porn addicts" had less brain activation (lower LPP) to still images of vanilla porn. I use quotation marks because Prause did not actually employ a screening instrument for internet pornography addicts, so we have no idea whether some, or any, of her subjects were porn addicts. For Prause's claims of falsification and the resulting dubious headlines to be legitimate, all of Prause's 55 subjects would have to have been actual porn addicts. Not some, not most, but every single subject. All signs point to a good number of the 55 Prause subjects being non-addicts

    The subjects were recruited from Pocatello Idaho via online advertisements requesting people who were "experiencing problems regulating their viewing of sexual images”. Pocatello Idaho is over 50% Mormon, so many of the subjects may feel that any amount of porn use is a serious problem. In a serious methodological flaw, none of the subjects were screened for porn addiction. In another methodological flaw, the ad limited recruitment to participants who had problems with only "sexual images". Since most compulsive porn users view streaming video clips, did this skew the participants even further?

    Make no mistake, neither Steele et al., 2013 nor Prause et al., 2015 described these 55 subjects as porn addicts or compulsive porn users. The subjects only admitted to feeling "distressed" by their porn use. Confirming the mixed nature of her subjects, Prause admitted in 2013 interview that some of the 55 subjects experienced only minor problems (which means they were not porn addicts):
    "This study only included people who reported problems, ranging from relatively minor to overwhelming problems, controlling their viewing of visual sexual stimuli."
    Key point: How can you debunk the porn addiction model if many of your "porn addicts" are not really porn addicts? 

    The Prause et al. finding aligns perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in heavy users (who were not addicts) when exposed to sexual photos (.530 seconds). Said the researchers:
    "This is in line with the hypothesis that intense exposure to pornographic stimuli results in a downregulation of the natural neural response to sexual stimuli."
    Kühn & Gallinat also reported more porn use correlating with less reward circuit grey matter and disruption of the circuits involved with impulse control. In this article researcher Simone Kühn, said:
    “That could mean that regular consumption of pornography more or less wears out your reward system.”
    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.”
    Put simply, men who use more porn may need greater stimulation for the response level seen in lighter consumers, and photos of vanilla porn are unlikely to register as all that interesting. Less interest, equates to less attention, and lower EEG readings. End of story.

    Prause et al. Concedes That Kühn & Gallinat May Be Right


    In the discussion section, Prause et al, cited Kühn & Gallinat and offered it as a possible explanation for the lower LPP pattern. She was on the right track, and it's too bad her interpretation then took a U-turn from her data. Perhaps Prause's strong biases against porn addiction shaped her interpretations. Her former Twitter slogan suggests she may lack the impartiality required for scientific research:
    "Studying why people choose to engage in sexual behaviors without invoking addiction nonsense"
    Incidentally, the still images employed by both Kühn and Prause differed significantly from the 9-second "explicit" video clips used in last year's Cambridge study, which found similarities between porn addicts' brains and those of drug addicts. Those researchers found greater reward center activity in porn addicts in response to the video clips, which is typical of addicts.

    Internet porn studies and their interpretation are complicated by the fact that viewing pornographic images (stills or videos) is the addictive behavior, rather than solely a cue. By comparison, viewing images of vodka bottles is a cue for an alcoholic. While that cue may light up her brain more than a control's brain, the alcoholic needs greater amounts of alcohol to get a buzz. The heavy porn users in the Kühn and Prause studies clearly needed greater stimulation (videos?) to exhibit their buzz. They didn't respond normally to mere stills. This is evidence of tolerance (and underlying addiction-related brain changes).

    Updates on Nicole Prause's twitter slogan:
    1. UCLA did not renew Prause's contract. She hasn't been affiliated with any university since early 2015.
    2. In October, 2015 Prause's original Twitter account is permanently suspended for harassment

    In Her 2013 EEG Study and a Blog Post Prause States That Less Brain Activation Would Indicate Habituation or Addiction


    Prause claimed that her 2013 EEG study was the first time EEG readings were recorded for so-called "hypersexuals." Since this was a "first" Prause admits it's pure speculation as to whether "hypersexuals" should have higher or lower EEG readings than healthy controls:
    "Given that this is the first time ERPs were recorded in hypersexuals, and literature on addiction (higher P300) and impulsivity (lower P300) suggest opposite predictions, the direction of the hypersexual effect was specified mainly on theoretical grounds." [That is, without much basis at all.]
    As explained here Prause's 2013 EEG study had no control group, so it could not compare "porn addicts'" EEG readings to "non-addicts." As a result, her 2013 study told us nothing about the EEG readings for either healthy individuals or "hypersexuals." Let's continue with Prause's views from 2013:
    "Therefore, individuals with high sexual desire could exhibit large P300 amplitude difference between sexual stimuli and neutral stimuli due to salience and emotional content of the stimuli. Alternatively, little or no P300 amplitude difference could be measured due to habituation to VSS."
    In 2013, Prause said that porn addicts, when compared to controls, could exhibit 1) higher EEG readings due to cue-reactivity to images, or 2) lower EEG readings due to habituation to porn (VSS). Five months before her 2013 EEG study was published, Prause and David Ley teamed up to write this Psychology Today blog post about her upcoming study. In it they claim that "diminished electrical response" would indicate habituation or desensitization:
    But, when EEG’s were administered to these individuals, as they viewed erotic stimuli, results were surprising, and not at all consistent with sex addiction theory. If viewing pornography actually was habituating (or desensitizing), like drugs are, then viewing pornography would have a diminished electrical response in the brain. In fact, in these results, there was no such response. Instead, the participants’ overall demonstrated increased electrical brain responses to the erotic imagery they were shown, just like the brains of “normal people”...
    So, we have 2013 Prause saying "diminished electrical response" would indicate habituation or desensitization. Now, however, in 2015, when Prause found evidence of desensitization (common in addicts), she is telling us "diminished electrical response" debunks porn addiction. Huh?

    In the intervening two years it took Prause to compare her same tired subject data with an actual control group, she has done a complete flip-flop. Now, she claims the evidence of desensitization that she found when she added the control group isn't evidence of addiction (which she claimed in 2013 it would have been). Instead, once again, she insists she has "disproved addiction." This is inconsistent and unscientific, and suggests that regardless of opposing findings, she will claim to have "disproven addiction." In fact, unless 2015 Prause rejects the 2013 Prause study and blog post she would be obliged to "invoke addiction nonsense."

    By the way, the above excerpt -"participants' overall demonstrated increased electrical brain responses to the erotic imagery" - is misleading. Of course it's normal to have a greater response to sexual pictures than to neutral landscape pictures. However, Prause's 2013 study had no control group, and it did not compare EEG readings of porn addicts to non-addicts. Once she added the control group, it was evident that arousal in response to erotic imagery is normal and the effect disappeared. Instead, her subjects turned out to be suffering from desensitization, an addiction process. In short, Prause's 2013 results were meaningless (see below), while her 2015 headlines contradict everything she had previously stated. She claims to disprove addiction while discovering evidence of it.

    Poor Methodology Once Again


    1) As with Prause's 2013 EEG study, the subjects in this study were males, females and possibly "non-heterosexuals". All evidence suggests Prause used the same subjects for her current study and her 2013 study: the number of females are identical (13) and the total numbers very close (52 vs. 55). If so, this current study also included 7 "non-heterosexuals". This matters, because it violates standard procedure for addiction studies, in which researchers select homogeneous subjects in terms of age, gender, orientation, even similar IQ's (plus a homogeneous control group) in order to avoid distortions caused by such differences. This is especially critical for studies like this one, which measured arousal to sexual images, as research confirms that men and women have significantly different brain responses to sexual images or films (Studies: 1, 2, 3,  4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14). This flaw alone calls into question both of Prause's studies.

    2) Prause's subjects were not pre-screened. Valid addiction brain studies screen out individuals with pre-existing conditions (depression, OCD, other addictions, etc.). This is the only way responsible researchers can draw conclusions about addiction. See the Cambridge study for an example of proper screening & methodology.

    3) The two questionnaires Prause relied upon in both EEG studies to assess "porn addiction" are not validated to screen for internet porn use / addiction. The Sexual Compulsivity Scale (SCS) was created in 1995 to measure sexual behavior to help with AIDS-risk assessment, and specifically not validated for females. 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."
    Like the SCS, the second questionnaire (the CBSOB) has no questions about Internet porn use. It was designed to screen for "hypersexual" subjects, and out-of-control sexual behaviors - not strictly the overuse of sexually explicit materials on the internet.

    A valid addiction "brain study" must: 1) have homogenous subjects and controls, 2) screen out other mental disorders and other addictions, and 3) use validated questionnaires and interviews to assure the subjects are actually porn addicts. Prause's two EEG studies on porn users did none of these, yet she drew vast conclusions and published them widely.

    A Pattern of Claims Unsupported by Data


    Prause, by her own admission, rejects the concept of porn addiction, and believes that porn use can never cause problems. For example a quote from this recent Martin Daubney article about sex/porn addictions:
    Dr Nicole Prause, principal investigator at the Sexual Psychophysiology and Affective Neuroscience (Span) Laboratory in Los Angeles, calls herself a “professional debunker” of sex addiction.
    Such inherent biases have lead to several claims by Prause, which do not align with her experimental data.

    The first example is her 2013 study "Sexual desire, not hypersexuality, is related to neurophysiological responses elicited by sexual images." Five months before this study was published, Prause released it (only) to psychologist David Ley, who promptly blogged about it on Psychology Today, claiming that it proved pornography addiction didn't exist. Such claims were not, in fact, supported by the study when published. The following excerpt is taken from this peer-reviewed critique of the study:
    ‘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.’
    Just as in the current EEG study, Prause claimed her subjects' brains did not respond like other addicts. In reality, her subjects had higher EEG (P300) readings when viewing sexual images - which is exactly what occurs when addicts view images related to their addiction. Commenting under the Psychology Today interview with Prause's claims, 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."
    This 2015 review of the neuroscience literature on porn addiction went further
    The study was designed to examine the relationship between ERP amplitudes when viewing emotional and sexual images and questionnaire measures of hypersexuality and sexual desire. The authors concluded that the absence of correlations between scores on hypersexuality questionnaires and mean P300 amplitudes when viewing sexual images “fail to provide support for models of pathological hypersexuality” [303] (p. 10). However, the lack of correlations may be better explained by arguable flaws in the methodology. For example, this study used a heterogeneous subject pool (males and females, including 7 non-heterosexuals). Cue-reactivity studies comparing the brain response of addicts to healthy controls require homogenous subjects (same sex, similar ages) to have valid results. Specific to porn addiction studies, it’s well established that males and females differ appreciably in brain and autonomic responses to the identical visual sexual stimuli [304,305,306]. Additionally, two of the screening questionnaires have not been validated for addicted IP users, and the subjects were not screened for other manifestations of addiction or mood disorders.
    Moreover, the conclusion listed in the abstract, “Implications for understanding hypersexuality as high desire, rather than disordered, are discussed” [303] (p. 1) seems out of place considering the study’s finding that P300 amplitude was negatively correlated with desire for sex with a partner. As explained in Hilton (2014), this finding “directly contradicts the interpretation of P300 as high desire” [307]. The Hilton analysis further suggests that the absence of a control group and the inability of EEG technology to discriminate between “high sexual desire” and “sexual compulsion” render the Steele et al. findings uninterpretable [307].
    Finally, a significant finding of the paper (higher P300 amplitude to sexual images, relative to neutral pictures) is given minimal attention in the discussion section. This is unexpected, as a common finding with substance and internet addicts is an increased P300 amplitude relative to neutral stimuli when exposed to visual cues associated with their addiction [308]. In fact, Voon, et al. [262] devoted a section of their discussion analyzing this prior study’s P300 findings. Voon et al. provided the explanation of importance of P300 not provided in the Steele paper, particularly in regards to established addiction models, concluding,
    "Thus, both dACC activity in the present CSB study and P300 activity reported in a previous CSB study[303] may reflect similar underlying processes of attentional capture. Similarly, both studies show a correlation between these measures with enhanced desire. Here we suggest that dACC activity correlates with desire, which may reflect an index of craving, but does not correlate with liking suggestive of on an incentive-salience model of addictions. [262]" (p. 7)
    So while these authors [303] claimed that their study refuted the application of the addiction model to CSB, Voon et al. posited that these authors actually provided evidence supporting said model.
    Bottom line: Three peer-reviewed papers agree with our analysis. The 2013 EEG study actually reported higher EEG readings (P300) when subjects were exposed to sexual photos. A higher P300 occurs when addicts are exposed to cues (such as images) related to their addiction. However, the study had no control group for comparison, which made the findings uninterpretable (as explained above this current study simply found a control group for the 2013 study). In addition, the study reported greater cue-reactivity for porn correlating to less desire for partnered sex. Put simply: The study found greater brain activation for porn and less desire for sex (but not less desire for masturbation). Not exactly what the headlines claimed about porn increasing "sexual desire."

    Similar to Prause's current study, her second study from 2013 found significant differences between controls and "porn addicts" - "No Evidence of Emotion Dysregulation in “Hypersexuals” Reporting Their Emotions to a Sexual Film (2013)." As explained in this critique, the title purposely hides the actual findings. In fact, "porn addicts" had less emotional response when compared to controls. This is not surprising as many porn addicts report numbed feelings and emotions. Prause justified the title by saying she expected "greater emotional response", but provided no citation for her dubious "expectation." A more accurate title would have been: "Subjects who have difficulty controlling their porn use show less emotional response to sexual films". This finding aligns with Prause's current EEG study and Kühn & Gallinat (2014), and indicates desensitization.

    In 2014, she openly teamed up with David Ley - author of The Myth of Sex Addiction, who has no background in the neuroscience of addiction or research - to produce a dubious review on the subject of porn addiction: "The Emperor Has No Clothes: A review of the “Pornography Addiction” model." It is this review that the authors cite for the astonishing proposition that, "The Internet has [not] increased viewing of visual sexual stimuli." Once again, virtually nothing in Ley & Prause "review" holds up to scrutiny, as this painfully detailed critique reveals - "The Emperor Has No Clothes: A Fractured Fairytale Posing As A Review."

    In summary, the three Prause studies on porn users align with the Cambridge studies and Kühn & Gallinat (2014).


    1) Sexual Desire, not Hypersexuality, is Related to Neurophysiological Responses Elicited by Sexual Images (2013)
    • Aligns with the 2 Cambridge studies: All 3 studies found cue-reactivity to porn, or sensitization. In addition, the Prause study reported less sexual desire for a partner correlating with greater cue-reactivity. In a parallel finding, the first Cambridge study reported that 60% of subjects had difficulty achieving erections/arousal with real partners, yet could achieve erections with porn.
    2) No Evidence of Emotion Dysregulation in “Hypersexuals” Reporting Their Emotions to a Sexual Film (2013)
    3) Modulation of Late Positive Potentials by Sexual Images in Problem Users and Controls Inconsistent with "Porn Addiction" (2015)
    • Aligns with Kühn & Gallinat (2014) in that more porn use correlated to less brain activation in response to sexual photos.
    • Aligns perfectly with 2013 Prause who said that lower EEG amplitudes (compared to controls) would indicate habituation or desensitization.
    Wouldn't it be great if journalists and bloggers actually read studies, and conferred with addiction neuroscientists, before rubber stamping sexologists' press releases or sound bites? Bottom line: All brain and neuropsychological studies published to date support the existence of porn addiction, including Prause's.

    Does Prause 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.
    It seems as though Prause is attempting to sell her services to profit from the claimed anti-porn addiction conclusions of her two EEG studies (1, 2), even though peer-reviewed critiques say both studies support the addiction model.

    As explained above, the first EEG study (Steele et al. 2013) actually found evidence for porn addiction. Her second EEG study, analyzed here, did nothing more than compare her 2013 subjects' EEG readings with an actual control group. That's right, the earlier 2013 study had no control group, which meant her sweeping conclusions were unfounded. As you have read, the current study also supports the concept of porn addiction.

    A recovering porn-user summed the situation up here: