Are You Hooked on Porn? Ask ASAM

AddictionLast month, 3000 doctors of the American Society for Addiction Medicine released a public statement bringing the definition of addiction into line with decades of addiction research. “[Addiction] is about brains…. It’s about underlying neurology, not outward actions,” explains ASAM’s Dr. Michael Miller.

ASAM’s definition captures the key elements of addiction described by NIDA head Nora Volkow, MD and her team in the review Addiction: Decreased Reward Sensitivity and Increased Expectation Sensitivity Conspire to Overwhelm the Brain’s Control Circuit Addiction behaviors are the consequence of measurable brain changes—and recovery entails reversing these changes. The telltale changes center around the reward circuitry of the brain: a numbed pleasure response, extreme sensitivity to addiction-related cues, and decrease in frontal-cortex function.

ASAM also affirms that sexual behaviors can be addictive:

We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors.

If you view porn, are you an addict or merely a user?

This question used to be a silly one for most porn users. Prior to the Internet, porn use (if any) bore some relation to authentic libido. When one had had enough, the magazine went back under the mattress. Internet porn, however, has the power to override natural satiety mechanisms in many brains. This increases the risk of the addiction-related brain changes ASAM addressed.

With respect to porn, it’s not time spent viewing or what you’re looking at that determines whether your brain has changed. Instead, watch for these signs:

  • Inability to abstain;
  • Impaired impulse control;
  • Cravings;
  • Diminished grasp of one’s problems; and
  • Problematic emotional responses. (Detailed ASAM list)

Curious how these telltale symptoms might show up in today’s porn users? We’ve culled the following questions from actual reports of self-identified porn addicts. Many users do not make the connection between their symptoms and their porn use until they abstain from porn for weeks, but these questions, and the remarks below them, may help you determine whether you need to seek help to reverse unwanted changes and restore your brain to balance.

  • Have you tried to stop using porn and failed? Did you notice withdrawal symptoms?
  • Do you experience intense cravings when you have no access to porn for several days?
  • When you use again do you notice rapid escalation to more extreme material?
  • Have you noticed changes in your sexual tastes?
    • Have you explored new types of porn in order to attain earlier levels of excitement?
    • Are you viewing things that never turned you on?
    • Are you using porn that does not match your sexual orientation?
  • Is porn viewing the most exciting thing in your life? Does life seem dull otherwise?
  • Do you feel powerless to stop yourself from using porn if you see or experience something you associate with porn use, such as:
    • being alone in the house,
    • seeing a TV show with your favorite fetish hinted at or portrayed,
    • seeing news about a favorite porn star?
  • Do you see potential mates differently—more as body parts than as people?
  • Since using Internet porn, do you feel more tongue-tied, unsafe, awkward or anxious around other people—especially potential mates?
  • Is it harder to connect with others? Do you feel lonelier? Are you more worried about what others think about you?
  • Have you (or those who care about you) noticed you:
    • procrastinate more than before using, have lower motivation (don’t care), chronic fatigue, brain-fog, or difficulty concentrating or remembering things?
    • have become more anxious, restless, impulsive, stressed, irritable, unhappy, pessimistic, emotionally numb, or depressed?
    • have become more secretive, or isolate more?
  • Have you noticed declines in your sexual function during sex: more rapid ejaculation (PE), inability to maintain an erection without self-stimulation, porn or porn fantasy (even if you can get rock-hard to porn), delayed ejaculation (or inability to orgasm), less satisfying orgasm, need the lights on during sex to get aroused, not turned on by attractive partner, no desire for sex?
  • Have you noticed declines in your sexual function during masturbation: unable to masturbate without porn or porn fantasy, need for more vigorous masturbation (“death grip,” faster strokes), weaker (or rapidly fading) erections, climaxing with a semi-erection, more frequent urination?
  • Since using Internet porn, do you feel like you’ve lost your “mojo,” or sex appeal? Do you doubt your attractiveness or feel more anxious about the dimensions/appearance of your genitals?
  • Does your voice feel more nervous, shallow, tight, or unnaturally high? Shallow breathing?
  • Have you masturbated to the point of abrasions or other physical damage?
  • Can you fall asleep without using porn? Do you have more trouble sleeping soundly through the night?
  • When under stress do you use more porn?
  • Do you have intrusive porn flashbacks?
  • Are you risking your job, education or relationship to watch porn, or spending too much money on it?
  • Have you lost a relationship or job, or dropped out of school due to your porn use (or symptoms related to it)?
  • After climaxing, do you notice more intense mood swings (irritability, depression, anxiety)?

These users have noticed symptoms that may indicate brain changes:

Juan: I’m 23. My family told me on numerous occasions I was a shell of myself compared to when I was 18 (in a loving way). My friends weren’t as direct with me, but it was clear. I wasn’t close to the same person. In only a few years of heavy porn use, I developed debilitating social anxiety, depression, lack of drive, physical exhaustion, mental exhaustion, couldn’t hold a job, couldn’t even walk down the university halls without feeling scared to death of people, felt creepy around females from young to old etc.

Greg: Every relapse to transsexual porn was my last one. (I’m straight.) Why was this material suddenly so enticing, in such a short time period? I was masturbating to material that disgusted me before, and would still disgust me after I orgasmed.

Ryan: I am afraid of binging if I use porn. I know from my recent experience that if I masturbate while watching porn, I do it continuously for days.

Davy: I had no concept that I was suffering from porn withdrawal. I had simply given up porn, as was my custom when dating a new girl. Apparently, I had never before reached this level of addiction. 90% of these symptoms were things I have NEVER experienced in my life. ALL of them have either been alleviated, or are significantly improved, by this point (13 days no porn/masturbation/orgasm).

  • Anxiety, chest tightness, panic attacks, high heart rate and blood pressure
  • Feelings of impending doom. Depression to the point of suicidal thoughts
  • Chronic Fatigue symptoms
  • Inability to take pleasure in anything whatsoever: eating, reading, watching a movie, playing music or creating artwork (I am a musician and an artist.)
  • Strange enjoyment of physical pain
  • Severe insomnia: total of about 18 hours of sleep over the course of three weeks
  • Increased urge to masturbate—up to 10 times in a day
  • Sexual fatigue, loss of libido, loss of interest in life, testicular and groin pain, but still a strong urge to masturbate (figure that one out)
  • ADD
  • Incoherent speech
  • Digestive problems
  • Headaches

Adrian: I never really knew how bad I was addicted until I tried to quit. I realize I can only get aroused with porn.

Tyrone: I have felt so emotionally numb for years now that I really feel like I have lost who I am. I don’t know what I feel about things. Nothing makes me happy/sad.

Ben: Had no idea I was addicted, which is funny considering I would spend hours a day in front of the computer watching increasingly novel video after video. If my Internet was running slowly and I couldn’t watch, I would go into rages and fits. I could do nothing else but wait until the video started again.

Tim: For about a month after giving up porn, I really couldn’t get hard enough to masturbate, and when I “forced” it my orgasms were pretty unsatisfying.

Will: I go all night until I’m exhausted, and then I go some more. I feel so tired the next day it’s unbelievable. I feel physically sick with body aches, a sore throat, red eyes, etc. It is very hard to focus on work. I stare at the computer screen, and forget what I am doing. Social anxiety is high after a relapse. I don’t want to be around anyone, and get irritated very easily. My body is extremely exhausted after a binge, but it is hard to fall asleep because my mind is worked up with anxiety. It’s like I’m only half there, just a shell of the man I could be. My voice is higher pitched, and sounds somewhat frail. I don’t even like looking in the mirror. Last time, there were a couple of girls interested in hanging out with me, but I got horribly stressed out at the thought of hanging out with them. I have zero libido after my masturbation marathon, and no desire to be around real women. All I feel is anxiety.

Kyle: I kinda just felt separate from everyone, and as a result would drink to excess in hopes of appearing more confident… Didn’t work LOL. Thing is, I used to be so confident and popular. I even saw a counselor about my ED, lack of confidence and social anxiety etc., but never was I asked about porn use.

Andrew: For a while at least, I always went back to the “tame” stuff in order to get off. There seemed to me something unseemly about getting off to something I was watching only out of a car crash rubber-necking, morbid curiosity. But then one day, I actually started masturbating to these kinds of videos. That’s when I knew I’d crossed the line. I was getting off to something I found repellant, not sexually arousing in the conventional sense. I could easily become aroused and orgasm via masturbation, but not when having sex with my wife. When you have difficulty being aroused or ejaculating with real partners, you know you’ve got an addiction. When you find yourself asking your spouse to put a live eel in her p—- while you f— her a–, and she says “No,” and you say, “You’d do it if you loved me. This is my fantasy.” That’s how you know you’re addicted.

Brains are plastic. That’s what makes them vulnerable to addiction, but it’s also what makes recovery possible. If you want to make a change, get support. Change is entirely possible. See additional self-reports of symptoms, escalation and withdrawal distress. Also see self-reports of effects reversing themselves after stopping.

Doctors Redefine Sexual Behavior Addictions

Logo: American Society of Addiction MedicineA major event has occurred in the realm of addiction science and treatment. America’s top addiction experts at The American Society of Addiction Medicine (ASAM) have just released their sweeping new definition of addiction. This new definition ends the debate over whether sex and porn addictions are “real addictions.” They are.

From the ASAM press release:

The new definition resulted from an intensive, four‐year process with more than 80 experts actively working on it, including top addiction authorities, addiction medicine clinicians and leading neuroscience researchers from across the country. … Two decades of advancements in neurosciences convinced ASAM that addiction needed to be redefined by what’s going on in the brain.

It’s likely ASAM acted, in part, because the psychiatrists who are revising the DSM (the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders) have been dragging their feet in bringing the upcoming DSM-5 into alignment with advances in behavioral addiction research. Traditionally, the DSM offers diagnoses based not on underlying disease, but on lists of behaviors. Since DSM authors can’t agree on a list of sexual behaviors that constitute “Hypersexuality Disorder” (which addresses compulsive porn use), they are hamstrung. In fact, they may banish the disorder to the appendix—right as Internet porn use among adolescent boys is becoming nearly universal.

In contrast, the ASAM definition, “looks at the role of the brain in the etiology of addiction—what is happening with brain functioning and specific brain circuitry that can explain the outward behaviors seen in addiction.” It is an acknowledgement that a sexual behavior (e.g., viewing Internet porn daily) may be evidence of pathology in one person’s brain without reflecting pathology in another’s.

Research shows that both behavioral and chemical addictions entail the same major alterations in brain anatomy and physiology. An ASAM spokesman explained:

The new definition leaves no doubt that all addictions—whether to alcohol, heroin or sex, say—are fundamentally the same. Dr. Raju Haleja, former president of the Canadian Society for Addiction Medicine and the chair of the ASAM committee that crafted the new definition, told The Fix, “We are looking at addiction as one disease, as opposed to those who see them as separate diseases. Addiction is addiction. It doesn’t matter what cranks your brain in that direction, once it has changed direction, you’re vulnerable to all addiction.” …Sex or gambling or food addiction [are] every bit as medically valid as addiction to alcohol or heroin or crystal meth.

Here is a brief summary of ASAM’s major points:

  1. Addiction reflects the same brain changes whether it arises in response to chemicals or behaviors.
  2. Addiction is a primary illness. It’s not necessarily caused by mental health issues such as mood or personality disorders. This puts to rest the popular notion that addictive behaviors are always a form of “self-medication” to ease other disorders.
  3. Both behavioral and substance addictions cause the same major changes in the same neural circuitry: Hypofrontality, sensitization, and desensitization.
  4. Engagement in chronic “addictive behaviors” indicates the above brain changes have occurred. Addictive behaviors then become unconscious and habitual.
  5. The new definition eradicates the old “addiction vs. compulsion” distinction, which was often used to deny the existence of behavioral addictions, including Internet porn addiction.

Unlike the brains of gambling, food, videogame addicts, the brains of sex/porn addicts have not yet been scanned. Yet the brain mechanics of behavioral addiction are already so well defined, that experts can say with confidence that sexual behaviors are also potentially addictive. In other words, it’s not the form or quantity of a stimulus, but rather the resulting brain changes, which matter. These excerpts from ASAM’s FAQs explain the science common to all addiction:

QUESTION: What’s different about this new definition?

ANSWER: The focus in the past has been generally on substances associated with addiction, such as alcohol, heroin, marijuana, or cocaine. This new definition makes clear that addiction is not about drugs, it’s about brains. It is not the substances a person uses that make them an addict; it is not even the quantity or frequency of use. Addiction is about what happens in a person’s brain when they are exposed to rewarding substances or rewarding behaviors, and it is more about reward circuitry in the brain and related brain structures than it is about the external chemicals or behavior that “turn on” that reward circuitry.(Emphasis added.)

Addicts share common brain changes, which show up in behavior as unsuccessful attempts to control use, cravings during abstinence periods, and withdrawal symptoms. To date, the underlying brain changes seen in all addicts (desensitization, sensitization, and hypofrontality) have already been observed in the brains of compulsive gamblers, overeaters, videogamers. It’s likely they are present in today’s compulsive porn users as well. If it walks, talks and acts like a duck, it’s a duck.

Another implication of ASAM’s statement is that one cannot define “porn addiction” by time spent viewing or genres watched. Porn addiction exists only if the relevant brain changes have occurred in the viewer. Since brain scans are impractical, ASAM has created a 5-part assessment to help people figure out if their brains have changed. This is similar to assessing diabetes markers in patients complaining of telltale symptoms.

These next two questions from ASAM address sex and food addictions specifically:

QUESTION: This new definition of addiction refers to addiction involving gambling, food, and sexual behaviors. Does ASAM really believe that food and sex are addicting?

ANSWER: Addiction to gambling has been well described in the scientific literature for several decades. In fact, the latest edition of the DSM (DSM-5) will list gambling disorder in the same section with substance use disorders.

The new ASAM definition makes a departure from equating addiction with just substance dependence, by describing how addiction is also related to behaviors that are rewarding. This the first time that ASAM has taken an official position that addiction is not solely “substance dependence.”

This definition says that addiction is about functioning and brain circuitry and how the structure and function of the brains of persons with addiction differ from the structure and function of the brains of persons who do not have addiction. It talks about reward circuitry in the brain and related circuitry, but the emphasis is not on the external rewards that act on the reward system. Food and sexual behaviors and gambling behaviors can be associated with the “pathological pursuit of rewards” described in this new definition of addiction. (Emphasis added.)

QUESTION: Who has food addiction or sex addiction?

ANSWER: We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors.

In short, sex addiction exists, and it is caused by the same basic alterations in brain structure and physiology as drug addictions. This makes perfect sense. After all, addictive drugs do nothing but increase or decrease normal biological functions. They hijack neural circuits for natural rewards, so it should be evident that extreme versions of natural rewards (junk food, Internet porn) can also hijack those circuits.

What about porn addicts?

Today’s healthcare providers and popular advice columnists are often misled about the risks of Internet porn use—in part because they know that masturbation (without porn) seldom results in addiction. Trouble is, Internet porn is not mere masturbation. The belief that masturbation and Internet porn are the same demonstrates a lack of understanding of the potential brain effects of constant novelty. Normally, masturbation leads to feelings of satiety. In contrast, Internet porn can override natural satiety. In some brains, overriding natural satiety with extreme stimulation is the slippery slope to addiction-related brain changes. This misunderstanding results in poor advice to patients/clients/readers.

When researchers someday look into the brains of Internet porn addicts, they are sure to see the changes already observed in other kinds of Internet addicts. Alas, porn-addiction research faces daunting challenges:

1.      Control groups of male, non-Internet porn users can no longer be found, and even if they could, review boards would certainly not approve protocols that call for them to watch the kinds of porn for as many hours a day as many of today’s young guys are watching.

2.      Vague questionnaires (unlike brain scans) make it tough for porn users to connect sexual performance problems (or social anxiety, depression or concentration problems) with Internet porn use. After all, porn seems like the world’s most reliable aphrodisiac, and users always feel better while using. How could it be causing the very problems it temporarily cures?

Only with broader knowledge of addiction, its symptoms, and its etiology can researchers and their subjects correctly connect cause with effect. The ASAM statement supports researchers in investigating porn use through the lens of brain changes.

Therapists have new responsibilities

ASAM’s declaration is a step forward in helping to reeducate therapists and their clients. Many were erroneously taught that sexual behavior addictions could not arise from overstimulation of the brain via behavior. Instead, they were trained to assure clients that addiction to sexual behavior was never a risk—unless the client had other (often genetic) disorders.

Yet ASAM authors estimate that genetics only make up about half the cause of addiction. This means that addiction can develop in the absence of pre-existing conditions. In other words, porn-related symptoms such as depression, social anxiety, youthful sexual performance issues and concentration problems need to be viewed as possible consequences of addiction, instead of being presumed always to be their cause.

The new statement thus places responsibility on therapists to help sex and porn-addicted clients make fundamental changes to their behavior. At the moment, many counselors simply refer clients to a doctor for psychotropic and sexual-enhancement drugs—while assuring them that their sexual behavior is typical and harmless.

The ASAM statement is a big step in a sound direction. In the following post, we consider specific symptoms porn users report, which may indicate addiction-related brain changes.