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[OldPsychDoc]

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So today, a married female patient come in steaming that her husband is a porn addict--and objectively I'd say, yeah, this guy's got a problem. He spends hours and she doesn't know how much money on pay sites. He's up until the wee hours and has been late for work as a result. Their marital relationship is in trouble emotionally and physically--she doesn't trust him, doesn't want him to touch her wondering if he's thinking about "them", etc.

So I'm thinking--what IS this guy's diagnosis, if he comes in to your office because she makes him "get help"? He's not psychotic, not using drugs. The behavior has been steadily increasing over time, but not episodic, like a mood disorder, or even associated with significant fluctuations in mood.
Is it a compulsion? "Impulse control disorder NOS"?
OTOH, it has features of substance dependence--if he's seeking ever increasing thrills (mere pictures of naked bunnies don't do it any more--he wants hard-core high-res video or nothing), one might say he's developing tolerance. Maybe he has cravings when he's not surfing it. It seems he might be consuming more than he intends. Don't know if he's tried unsuccessfully to cut down. Looks like he's spending a lot of time in efforts to get his "fix", and that he's certainly giving up other important pursuits to seek and consume it. Will he keep going in spite of adverse consequences??? Maybe it really IS an addiction?

What do y'all think? What's the natural history of this illness? Or is it just a moral failing? Maybe a benign preference? Is it the wife's problem, not his?

 

[bjolly]

since it's hurting (and possibly endangering) his marriage, and it's affecting his job, I'd say he's already gone on in spite of adverse consequences. Having known someone like this, I feel it resembles an addiction more than anything else. Maybe the most similar recognized problem is compulsive gambling, since it's a compulsive behavior with negative consequences but no "substance" involved. How is obsessive gambling categorized clinically? is that considered an addiction?

 

[OldPsychDoc]

since it's hurting (and possibly endangering) his marriage, and it's affecting his job, I'd say he's already gone on in spite of adverse consequences. Having known someone like this, I feel it resembles an addiction more than anything else. Maybe the most similar recognized problem is compulsive gambling, since it's a compulsive behavior with negative consequences but no "substance" involved. How is obsessive gambling categorized clinically? is that considered an addiction?

As Pathological Gambling, in the category of "impulse control disorders". It has a DSM code (312.31) of its own.

 

[bjolly]

interesting. I think for this case I'd go with Impulse Disorder NOS. In the case of the person I knew, divorce turned out to be a very effective treatment. For the wife. 😀

 

[sdn1977]

I'm confused - who is your pt - the wife or the husband? If the husband, did he come willingly identifying any issues of his own (trying to lose himself in something - the porn - to avoid something else - the wife or work?).

If the husband, does he admit any of these sx & provide any hx of their appearance. If the husband also....are there any other physiologic disorders which need to be ruled out prior to a dx of impulse control problem?

I don't know anything at all about these diseases (if they are indeed diseases), but what other things should be considered before you get to the dx?

And...since I'm interested in the drug side....do SSRI's help with these types of compulsions?

 

[OldPsychDoc]

I'm confused - who is your pt - the wife or the husband? If the husband, did he come willingly identifying any issues of his own (trying to lose himself in something - the porn - to avoid something else - the wife or work?).

If the husband, does he admit any of these sx & provide any hx of their appearance. If the husband also....are there any other physiologic disorders which need to be ruled out prior to a dx of impulse control problem?

I don't know anything at all about these diseases (if they are indeed diseases), but what other things should be considered before you get to the dx?

And...since I'm interested in the drug side....do SSRI's help with these types of compulsions?

To clarify, the wife is my patient, the remainder of my post is hypothetical musing--if the husband were to present for "help". (Of course, they usually don't think they have a problem...) I'm also going to add, this is not a unique or unusual case--it comes up at least a couple of times a year in my practice.

I think you would need to rule out a mood disorder, esp bipolar, but in the majority of these cases it's not there.

I didn't even pose the treatment question--but it's a good one. What would you do? SSRIs are certainly tried. I'm sometimes tempted to go for the big whompin' dose of risperidone to pump his prolactin, get him to grow some breasts, and shut down the libido, but that's mostly fantasy.

 

[sunlioness]

It sounds like an addiction to me, but then again unlike the DSM I've always that that porn, gambling, food, sex addictions were true addictions. And by the same token, why couldn't substance abuse be an impulse control disorder? They're all the same thing to me no matter what it is you can't stop yourself from doing or "need" in order to dull your internal pain.

 

[Chrismander]

at the risk of of saying something really crass and insensitive... although kind of hinted at by the last sentence of your first post re: whether this is a "moral problem" or personal preference rather than a psych issue:

lots of religious people would consider looking at ANY porn ever to be a major sin. lots of feminists would likewise consider all porn to be a misogynistic exploitation of women. some women might be pretty neutral on the issue until they felt personally wounded, like that the porn was actually a real competitor for their partner's affections (hinted at by your statement that she doesn't want to be touched by him because [God forbid] he might be thinking of someone other than her). and some pro-sex types think porn is the greatest thing since sliced bread and that it adds to relationships in the right dosages.

So isn't there a real cultural dimension to all this? I guess what i'm trying to say, is we have to consider both of their baseline attitudes towards porno before this problem ever surfaced, as well as any attitudes in their culture and religion bring in. as in, a super religious or feminist wife might see a guy looking at porn merely when she's not in the mood as a "porn addiction" while another wife might look at that same behavior as a welcome relief from the pressure or guilt to have sex when she doesn't feel like it. Likewise if the woman is one of the latter and she's still complaining about the guy's porn habits, then he's probably a twit.

a few random thoughts:
1) is the porn the real problem? we're all acting like this is some sort of isolated addiction in the husband without considering a larger context. i believe porn addiction is real, but that it's also different than alcohol or drug addiction as the sexual drive involved in the addiction is also an intrinsic part of the relationship. was there a problem in the relationship before the porn? the guy loses physical interest in the wife because of underlying emotional / relationship problems, and porn becomes his sexual outlet. if that's the case the guy could go cold turkey on the porn and still never touch his wife again 'cause he's locked in the bathroom fantasizing about someone else sans porn... same problem, different wrapping.

2) risk of crassness: has the wife's appearance changed drastically recently? this will get me flamed, but maybe he's not attracted to her any more, and she's super sensitive about her appearance which is making the porn even more painful to her? hinted at by her being freaked out that he might be thinking about the porn bunnies when he touches her. lots of people fantasize about other people occasionally during sex...it's going to bother someone who either has their own self-esteem issues (#2 here) or else if the relationship is on the rocks for other reasons (#1 above).

3) is any level of porn tolerable to her? This is another flame-worthy topic, due mainly to the scant info we have available here about the overall situation (i.e. i might not say anything like this if i knew more about the situation and felt certain the husband was being a total and complete douchebag), but...
i find it a little weird (though this says more about my own personal "moral" values than anything I suppose) that the wife is so hysterical about him looking at porn that she's not even accepting the advances he is making. Some couples use porn together to spice up their lovemaking. Some husbands might look at a little porn and then go to their wives reinvigored. Is there any way she'd be amenable to trying to watch a porno with him and making it more of a couples' thing? This may be a pointless effort, as he might already be so withdrawn from the relationship that the porn is just another way for him to escape and he'd never really go along with it--but the fact that he's still angling for some nookie and she's rejecting makes me think it's at least plausible. i mean, what guy wouldn't want to watch a porno with his wife?
but enough of me sickening you all with my liberal East Coast values. 😳 Flame away.

 

[Dartos Vader]

Is that an excessive amount? I mean, uh, of course it is! That stuff is disgusting!

 

[ParisHilton]

😉 just kidding!

http://www.youtube.com/watch?v=h5OZzp7HSKs&mode=related&search=
http://www.youtube.com/watch?v=IPUZYSZLrJA&mode=related&search=
http://www.youtube.com/watch?v=HjDJhRk8kB0
http://www.youtube.com/watch?v=L_kADup_wZw

 

[i61164]

So if we say that porn addiction is a legitimate illness, does that make him less responsible for his actions? Is an alcoholic or drug addict less responsible for their actions because they are "sick?" I can definitely see how porn addiction could be a hormonal problem, so maybe this is not too far fetched to say that it's an illness and we can fix it with medicine.

I guess the photo on the previous post got me thinking. Do these people need to be locked up (or maligned in the case of porn addicts), or do they need treatment? I mean, some of these guys are repeat offenders and they walk up to the house even though they are pretty sure that it is a Dateline trap.

 

[maranatha]

Do these people need to be locked up (or maligned in the case of porn addicts), or do they need treatment?

They need both.

 

[jjbmsiv]

You would seriously lock someone up for being addicted to porn? My libertarian viewpoint is shocked! *laughs* Though, really, I can't see the point. Just like with the how-many-now locked up in jail for marijuana possession. I mean, even if it's looking at not filming, those guys deserve much worse) kiddie porn, the person needs HELP, not jailtime. What does jailing this kind of person accomplish? It certainly doesn't help them cope with their addiction. That requires psychiatric care, I would think. If the addiction interferes with a person's ability/desire to work/eat/bathe/ADLs, then it definitely warrants strong intervention. Not prison bars, though.

 

[maranatha]

You would seriously lock someone up for being addicted to porn?

No. The quote I was referring to was his reference to the child molesters caught on Dateline, not the porn addicts ("these people" was in reference to the Dateline photo and child molesters, at least that is what I thought he meant).

 

[jjbmsiv]

That'll teach me to half-ass read a post! *laughs* 🙁 My apologies!

 

[i61164]

These guys on Dateline have broken the law, but what they have done is not that much worse than people that surf kiddie porn all day (or "barely legal" sites). And they get locked up before they even touch an underaged girl (kinda like in the movie Minority Report). I'm not saying we don't want these people off the streets, I myself have a young daughter. What I'm saying is that we look down on these people and think that they are scumbags (even the ones that haven't technically broken any laws). If their behavior is a legitimate illness, should we maybe change the way we think about these people and show a little more empathy?

 

[maranatha]

These guys on Dateline have broken the law, but what they have done is not that much worse than people that surf kiddie porn all day (or "barely legal" sites).

Are you sure about this? Isn't there something about "intent" to engage in an unlawful act? What these guys are doing goes much further then just having a thought or fantasy. They are going to the point of engaging in sexually explicit conversation with a known minor and then actually going to a location to meet that child. I'd say this is going way, way too far and is pretty scary. I'm not sure what you're referring to with not doing much worse than people that surf kiddie porn...It is illegal to knowingly and willingly look at kiddie porn on the web.

 

[i61164]

It just seems to me that the porn addicts and the Dateline guys are at different spots on the same spectrum. Because some of the Dateline guys do it anyway even though they are pretty sure that they are going to get caught and go to jail makes me think that they have an illness. They are knowingly ruining their lives. Some of them probably think they can get away with it, but in the episode that I watched it seemed like a lot of these guys weren't even surprized that it was a sting operation. Some of them just sit down, have a cookie, and talk to the camara before heading off to jail. The non-criminal porn addicts may just have a lesser version of this illness. Maybe this is a forensic psych question, but I wonder what does it take to prove that someone was not fully "responsible" for their actions because they have a psychiatric illness. I'm just really curious about this.

 

[Anasazi23]

Maybe this is a forensic psych question, but I wonder what does it take to prove that someone was not fully "responsible" for their actions because they have a psychiatric illness. I'm just really curious about this.

It is a forensic question, and one that is way beyond the scope of this thread, but it essentially boils down to the concept of "mens rea" or having the "guilty mind." The forensic psychiatrist's job is to help delineate if mens rea existed at the time of the offense. And for a jury to make a ruling on evidence (professional opinion) from plaintiff and defense.