Good afternoon. So here we are with the last but long-awaited topic of the fourth symposia, and I am so excited to hear about the next topic, behavioral addiction in 2023, clinical considerations relating to gambling, gaming, sex, digital technologies, and other behaviors. And our chair is Dr. Mark Potenza. He and I, I think, worked many, many, many years ago, and since then I am so happy to see him come back to us. He actually is an expert in behavioral addiction with board certification in addiction psychiatry, and he is a full professor of psychiatry, child study, and neuroscience at the Yale University School of Medicine. He is also the director of the Division on Addiction Research, the Center of Excellence in Gambling Research, the Women and Addictive Disorders Core of Women's Health Research at Yale, and the Yale Research Program on Impulsivity and Impulse Control Disorders. He is on the editorial board of over 15 journals and has received multiple national and international awards for excellence in research and clinical care. He has consulted to the Substance Abuse and Mental Health Services Administration, National Registry of Effective Programs, NIH, American Psychiatric Association, and WHO on matters of addiction. He has participated in DSM-5 text revision, two DSM-5 research workgroups, and six annual WHO meetings relating to internet use, addictive behavior in the ICD-11, addressing the topic topics related to gambling, gaming, impulse control, and addiction. So I welcome Dr. Mark Potenza, who is also the president-elect of ISAM, which is another strong collaborative partnership that AAAP is looking forward to. With that, I will have Dr. Mark Potenza introduce his panel and also begin his presentation. Thank you. Thank you. Thank you for the kind introduction. And we'll do brief introductions before each speaker. And the speakers are Professor Mateusz Gola and Shane Krauss. But I will be talking first on behavioral addictions in the DSM-5 and the ICD-11. I have a listing of disclosures. Okay. Wonderful. Thank you. So I have a listing of disclosures with respect to pharmaceutical, gambling, gaming, and legal entities. And these are Mateusz's disclosures, which I think have been migrated here into the onset. And these are Shane's disclosures. And so these are the objectives to appreciate the DSM-5 and ICD-11 and how they consider behavioral addictions, as this is a relatively new area for both nomenclature systems, to understand the treatment approaches, particularly as ICD-11 has new diagnostic entities for which there will be new coding entities so that when clinicians, when the U.S. adopts ICD-11, it will be important for many perspectives to understand these phenomena. And then to consider how co-occurring disorders relate to behavioral addictions in their treatment. So going back now 20 years, Constance Holden had a couple of articles in the journal Science where in the first she asked whether behavioral addictions existed and whether we might use new technologies to understand gambling and other behaviors. And then in 2010, she heralded the reclassification of gambling disorder, what was in DSM-4 termed pathological gambling, the reclassification together with substance use disorders in DSM-5. And so the two main nomenclature systems, I would argue, have now more fully considered behavioral addictions, but there is still more to consider as there are still gaps in both nomenclature systems with respect to behavioral addictions. So what is the history of gambling disorder? So gambling disorder was introduced in DSM-3 in 1980 as pathological gambling. It was classified as an impulse control disorder. There were revisions to the diagnostic criteria that occurred, going from DSM-3 to DSM-3R to DSM-4 to DSM-5. But big changes going from DSM-4 to DSM-5 included not only the reclassification, but also the dropping of the illegal acts criterion as well as the threshold. So the threshold of four of nine inclusionary criteria being needed to meet a diagnostic threshold, and this is still much more stringent than, for example, substance use disorders which require two of 11. And these changes were made based on existing data at the time. So I would argue that we still don't know as much about the treatment of behavioral addictions as we do other psychiatric disorders. And the disorder, the behavioral addiction for which we have the most knowledge is gambling disorder. But in all cases, there are no medications that have an FDA indication for any of the behavioral addictions. That being said, behavioral addictions often co-occur with other disorders for which there are medications with formal indications, and I'll present some of the data on the co-occurring disorders with respect to gambling disorder. So arguably, the most important need in the clinical realm is to identify people with gambling disorder. So it's estimated that 10% or less of individuals with gambling disorder ever seek treatment. So the vast majority of people do not seek treatment. And data that we have from screening and identifying individuals, for example, in inpatient mental health care settings and outpatient mental health care settings, suggest that these often go undiagnosed, untreated, and that those individuals with these conditions, they often experience poor treatment outcomes, both in the targeted domain for treatment, be it depression, anxiety, substance use disorders, or generally overall. Thus, screening individuals and identifying individuals is of particular importance. So there are many barriers that exist for people coming into treatment. People like people with substance use disorders. There may be shame, stigma, guilt, or ambivalence or unwillingness to enter into treatment. So oftentimes, people are not willing to bring up on their own their behaviors in these realms. And it's often important to do so in a nonjudgmental fashion, ask about gambling behavior or gaming behavior or pornography use, as we'll hear later. So what are the data on co-occurring disorders? So data from the National Comorbidity Replication Study estimate that 96% of individuals with gambling disorder have one or more co-occurring disorder, and close to two-thirds have three or more co-occurring disorders. So the co-occurrence is more the norm than the exception. And these co-occurring disorders might help with respect to selecting appropriate treatments for individuals. These are those data from the National Comorbidity Replication Survey data, color-coded into substance use disorders, impulse control disorders, anxiety disorders, and mood disorders. And as one can see, substance use disorders frequently co-occur, particularly tobacco use disorder, which occurs in the majority of individuals. But also, anxiety disorders and mood disorders occur commonly. So what drove the reclassification of gambling disorder with substance use disorders? So related to multiple similarities, not only the high rates of co-occurrence, but also the similar clinical courses with high rates of the conditions in adolescents and young adults, lower rates in older adults, telescoping phenomenon that initially was reported for alcohol use disorder, later for drug use disorders, and then subsequently for gambling disorder. And then similarities in the clinical characteristics, some of which are reflected in the diagnostic criteria with elements of tolerance, withdrawal, frequent repeated attempts to cut back or quit unsuccessfully, as well as interference in major areas of life functioning. And then some of the similarities in the biologies may link to similarities in the treatments that have been found to be helpful for people in multiple domains, self-help, behavioral, and pharmacological. So what are some of the biological similarities? So in a meta-analysis, Marcia Lutchen and colleagues found that individuals with addictive disorders, be it substance use disorders or gambling disorders, showed relatively blunted activation of the ventral striatum during the anticipatory phase of reward processing on the monetary incentive delay task. This seems to also tend to extend to individuals with internet gaming disorder. So what can we take away from the pharmacological treatment of other frequently co-occurring conditions? And maybe this could help us in terms of treating people with gambling disorder. So while there are no FDA-approved medications for the treatment of gambling disorder, there are for alcohol use disorder. And there are shared genetic contributions to the conditions. And if we think about the medications that have indications for alcohol use disorder, we thought that naltrexone, a mu-opioid receptor antagonist that may reduce craving and diminish engagement in addictive behaviors, might be suitable for testing in the treatment of gambling disorder. And four randomized clinical trials of either naltrexone or another opioid antagonist, nalmephene, have been found to be superior to varying degrees, superior to placebo in the treatment of gambling disorder. And these are data from one of the larger multicenter trials, close to 200 individuals, where nalmephene at 25 milligrams per day, which is roughly equivalent to naltrexone at 50 milligrams per day, was found to be the most efficacious dose. And in this study, nalmephene was superior to placebo. And the 25 milligrams per day dose was also the most well-tolerated. But even at the most well-tolerated dose, not everyone was a responder. And in the placebo arm, slightly over one-third of individuals were responders. So we were interested in understanding whether there were clinical characteristics that were associated with better treatment response. So John Grant, myself, and others, pooled data from two randomized clinical trials, one of naltrexone, one of nalmephene. And we found that the factor that was most robustly associated with better treatment outcome in the active drug treatment arm, from a statistical perspective, was a family history of alcoholism, consistent with this idea that perhaps there is something that cuts across the disorders that might be effectively targeted with the opioid receptor antagonist. We also found that those individuals who had strong gambling urges at treatment onset were more likely to respond to active medication. When we looked at the placebo data, we didn't see these relationships. Statistically, the most robust relationship was with respect to age, where younger individuals were more likely to respond to placebo. So in another study that Izmini Petrakis was conducting, we incorporated measures of problem gambling. And what we found was that in this study of individuals with alcohol use disorder and one or more other co-occurring disorder, a non-gambling disorder, we found that slightly over 6% of individuals met criteria for gambling disorder. And this is significantly higher than the 0.2% to 0.3% of individuals in the general population who are thought to meet criteria for gambling disorder. And a quarter of the individuals had one or more criteria for gambling disorder. So when we looked at that group that had some gambling disorder features, we found that that group showed less improvement with respect to drinking days per week and with respect to improvement in other psychiatric symptomatology. So again, highlighting the need, and in this case, this was a group of veterans, highlighting the need for active screening and intervention. So in a separate randomized clinical trial multicenter study that John Grant led, this was a serotonin reuptake inhibitor. We found that close to 50% of individuals responded to active drug, slightly over 50%. It was 59%. However, close to 50% of individuals also responded to placebo. So at the end of the trial, there was not a between-group difference. So we were interested in perhaps whether a subgroup of individuals might respond better to serotonin reuptake inhibitors. And so we did a subsequent small open label followed by double-blind discontinuation study in individuals with gambling disorder and co-occurring anxiety disorders, and found that during the open label phase, the individuals with the gambling disorder and co-occurring anxiety disorder showed somewhat parallel decreases in anxiety and in problem gambling severity. What's not shown here is that the individuals who were randomized to active drugs showed a continuation of their improvement, and those randomized to placebo showed a worsening. Now gambling disorder may also share features with mood disorders. And in this case, studies that Hilary Blumberg led with looking into the neurobiology of bipolar disorder and that we led looking into the neurobiology of gambling disorder suggested that both affected groups, as compared to those without, showed relatively blunted activation of the ventromedial prefrontal cortex during a cognitive control task. In this, brain region has been implicated in decision-making, mood regulation, and other processes. So it raised questions whether individuals with gambling disorder and bipolar symptomatology, described here as bipolar spectrum disorder by Eric Hollander and colleagues, whether they might respond to a mood stabilizer. And what's shown here is that lithium was superior to placebo with respect to reducing symptoms of both problem gambling severity and mania. So based on those data, we've proposed a treatment algorithm where if individuals are less willing to consider drug treatment, then N-acetylcysteine, which has shown some promise in the treatment of individuals with certain substance use disorders, might be willing to try. There are data from John Grant and colleagues that suggest that N-acetylcysteine is superior to placebo with respect to improving problem gambling symptomatology. And then based on the presence or absence of specific co-occurring disorders to consider opioid receptor antagonists like naltrexone, mood stabilizers like lithium, or serotonin reuptake inhibitors. And this is a work in progress. However, behavioral therapies are the mainstay of treatment with arguably the most data for cognitive behavioral therapy, but also imaginal desensitization, which involves the decoupling of cues from the behavior, has support, as well as motivational interviewing. And there are several approaches to cognitive behavioral therapy, one that Nancy Petrie has tested that is based on Bruce Rounseville and Kathy Carroll's cognitive behavioral therapy for people with substance use disorders, as well as one that Robert Lattesieur developed that focuses more on these irrational cognitions that people with gambling problems often have relating to luck and odds and the like. Now GA is also a widely used self-help form, and there are data to suggest that it, too, is helpful for individuals. Now one approach that we have been developing recently is to take the cognitive behavioral therapy that Nancy Petrie has developed and use the computer-based treatment for cognitive behavioral therapy approach that Kathy Carroll and colleagues have used for substance use disorders and develop a digital intervention to help overcome factors like geographic boundaries, appointment times, delivery of therapy, some of the factors that we heard about in this morning's session. And we are now developing the app, and we're going to test it in a randomized clinical trial. Before doing so, we also reviewed the literature on the apps that are available, and what we found using the Mobile App Rating Scale, or MARS, was that the apps that had CBT elements or a community engagement feature seemed to be higher rated than those that did not. So based on the existing data, this is too busy a slide to go through. We've created and published a Nature Reviews Disease Primer article, a treatment algorithm that incorporates behavioral interventions and pharmacological interventions based on severity of gambling disorder as well as co-occurring disorders. Now another area that is showing promise, but there are no FDA indications like there are, for example, with tobacco use disorder, is neuromodulation. But there are data that have been emerging with respect to targeting craving in people with gambling disorder as well as individuals with internet gaming disorder. So I'm going to shift gears a bit and talk about the ICD-11 as compared to the DSM-5. The DSM-5 introduced in 2013 internet gaming disorder into Section 3, the research section. The criteria are very similar to those for gambling disorder. And the threshold is a bit more stringent than for gambling disorder. So one needs to meet five of nine inclusionary criteria rather than the four of nine. So we've been interested in understanding the similarities and differences with respect to problematic gaming as well as problematic internet use. And in this study of adolescents, we found that youth with features of problematic internet use showed blunted reward-related activation via EEG, suggesting that there may be a link in this area. Similarly, in a study that Guanghan Dong and colleagues conducted in China, we found that there was decreased resting state functional connectivity in an executive control network during performance of an executive control task that linked to out-of-the-magnet measures of cognitive control, again, fitting with dual process models of addictions. Similarly, in a meta-analysis, this meta-analysis implicated relatively decreased brain volumes, gray matter volumes, in individuals with internet gaming disorder in the ventromedial prefrontal cortex, anterior cingular cortex, and other brain regions, so some of the brain regions that NIDA has linked to motivational drive and behavioral control. So based on these data, we've proposed models of internet gaming disorder, and we've also reviewed the interventions for internet addiction, gaming disorder, and neuromodulation for treatment of problematic use of the internet. With respect to manualized therapies, Klaus Wolfling and colleagues has developed what they have termed the Shtika approach, short-term treatment of internet and computer game addiction. In this randomized controlled trial, their cognitive behavioral therapy was superior to the control condition. And in data that we collected in China, we found that neuromodulation, stimulation of the right dorsolateral prefrontal cortex in individuals with internet gaming disorder was linked to better regulation of affect and of craving. So going into the ICD-11, there were a number of questions with respect to how the ICD might consider gambling, gaming, as well as hypersexuality, as hypersexual disorder was considered but excluded entirely from DSM-5. So in anticipation of the ICD-11, a group of us met going back to 2014 on an annual basis. We put out position pieces that other people in the scientific community, there was debate on whether gaming disorder should be a formal diagnostic entity. This was reflected in the common media, the general media, where on back-to-back days, game addict disorder as a moral panic was juxtaposed with the National Health Services to open an addiction clinic for young online gamers. And there were reports in the news about young individuals getting into oppositional behaviors about internet use and gaming behaviors. So we thought it was important to communicate the importance of including gaming disorder in the ICD-11 from a clinical and public health perspective. The gaming industry came out with a unified statement opposing the inclusion of gaming disorder in the ICD-11 back in 2018. We wrote back a commentary in Addiction involving over 120 authors asking whether this was a corporate strategy to disregard harm and deflect social responsibility, remembering that it was only about 30 years ago when the tobacco industry went in front of Congress and testified that they didn't think that tobacco was an addictive product. So what happened at the World Health Assembly in May 2019? So gambling and gaming disorders were included as disorders due to addictive behavior. So this is a new classification area. Hazardous gambling and hazardous gaming were included as new entities, similar to hazardous alcohol use, for example. And then compulsive sexual behavior disorder was included as an impulse control disorder, but not as a disorder due to addictive behaviors. So this recaps some of the similarities and differences with respect to the ICD-11 and DSM, where there are specific sections in both nomenclature systems for the behavioral addictions and the clinical entity of gambling disorder being included in DSM-5, but both gambling and gaming disorders being included in ICD-11. As in the DSM-5, gambling disorder replaces the term pathological gambling to reduce potential stigma associated with the name of the condition. And a difference is the specifier. So the specifiers in the DSM-5 are based on severity for gambling disorder, based on the number of inclusionary criteria. And in the ICD-11, it's predominantly offline and predominantly online, being the specifiers with an unspecified descriptor also included. And then the exclusion criteria for gambling disorder of not better accounted for by bipolar disorder types 1 or 2 is partially reflected in the ICD-11. It seems currently written as a more hard exclusion criterion, but there is now talk of language to pull that back to be more in line with DSM-5. So what are the actual criteria? So these are the criteria for gaming disorder. And I've highlighted in orange the core features of impaired control, the gaming taking precedence over other interests and activities. And there's the continuation despite the occurrence of negative consequences. There also has to be impact on major areas of functioning, and that this should be evident for at least 12 months, but there's flexibility if all criteria are met within a shortened timeframe. Now hazardous gaming and gaming disorder are mutually exclusive entities where the hazardous does not reach the diagnostic level. And there are some potential evidence in the literature and in the general community of hazardous gaming. So for example, at one hospital there was a patient who died while a nurse's aide was playing video games. So this is one example. Now these are the core features of hazardous gaming. It appreciably increases the risk of harmful physical or mental health consequences relating to the gaming behavior, and it relates to multiple aspects of the gaming behavior but does not reach the level of a disorder. Compulsive sexual behavior disorder, which we'll hear more about in the subsequent talks, is characterized by the failure to control the urges or impulses. It becomes a central focus to the point of neglecting important activities. There are unsuccessful attempts to control the behavior, and there's continued engagement despite adverse consequences. So those are all features of addictive disorders. And then the compulsive aspect is reflected in the repetitive sexual behavior, even when individuals derive little or no satisfaction from the behavior, which may also apply to addictive behaviors. It also goes on to state that there needs to be an impact in major areas of life functioning, and that this is not entirely related to moral judgments and disapproval about the sexual impulses, urges, or behaviors. And we'll hear more about that in the subsequent talks. Now there are a number of behaviors, like use of social media or shopping and buying that can be done offline or online, that are not considered in the ICD-11 specifically nor in the DSM-5, but still may represent important concerns for people coming into treatment. So there is this designation of other specified disorders due to addictive behaviors in the ICD-11, and this could be a diagnostic entity to consider for such individuals seeking treatment. So I'll conclude by saying that while there has been significant progress made in understanding the characteristics with gambling disorder in their treatment, there's still a lot that we need to learn, and we know far less about other behavioral addictions. So there are these gaps that exist between our clinical understanding and optimally the information that we would like to have in treating individuals. But as clinicians, we need to see people and help them in the here and now and use as much empirically supported interventions as possible. It's going to be important to identify these individuals and to use the existing empirically supported approaches, but also we need to develop more interventions. So I'd like to thank a large number of individuals and funding agencies, and thank you all for your attention. And so I'd like to introduce Mateusz Gola, who is a professor at the University of Warsaw and also has a joint appointment at the University of California, San Diego, who will be talking on Problematic Pornography Use and Other Compulsive Sexual Behaviors, Neurobiology and Treatment. Thank you very much. It's a great pleasure to be here. I'll just share a joy that last week I became a father, so please forgive me my messy hair. And let's start. So those are the funding for the research I was conducting during the last years and the overview of this talk. So here I will tell about how to diagnose compulsive sexual behaviors, how to diagnose problematic pornography use. I will say a few words about subtypes of patients seeking treatment for problematic pornography use, as this is the most common group, and about psychological mechanisms of compulsive sexual behaviors and neuronal mechanisms of CSBD and PPU, and then about treatment approaches for each subtype of CSBD patients and PPU patients. And objectives. First of all, to know how to diagnose compulsive sexual behaviors and problematic pornography use according to ICD-11 guidelines, and what are the available screening tools, and then to identify and conceptualize subtypes of patients with those problems, and to be able to explain to your patient how the underlying mechanisms work, and then how to select the appropriate treatment approach for each PPU or CSBD patient subtype. Who have seen any of those movies, Don John or Shame? Okay, only a few people. So I highly recommend those movies as they present cases of patients I'll be talking about during the next 20 minutes, and they are especially Shame by Stephen McQueen. This is a really good movie. So in those movies you can see how it looks like to have a better picture, but also recently BBC produced the Planet Sex series, which is available at Hulu, and it's also featuring our studies, so I also recommend this one. And what is most important for us, we have also ICD-11 where we have description of the diagnostic criteria. Okay, so let's start from the statistics. How many people watch porn? Only one most popular website, which is Pornhub, attracts about 33.5 billion visits a year, which is 92 million people a day, which is equal to combined population of Canada, Poland, and Australia, including all children and elderly adults, everyone. So this is the daily number of visits for only this one website. When we conducted studies on the representative samples, both in US or European countries, in this case this graph comes from the Polish sample, we see that approximately about 48% of adult males watch pornography on monthly basis, and 23 to 27% of adult women, and we were conducting both self-declared measures and objective, analyzing objective data, tracking them, what people are watching on their devices. So we can see that this is very popular entertainment, and for majority of users it is not a problematic behavior, but for some it is. So for how many? Okay, so here we have data from the International Sex Survey, it's a multi-site study conducted in multiple countries, and here we are asking people if they consider their pornography use as problematic or not, and approximately about 8 to 11% of males, adult males, are saying that for them it is problematic, and this is a problematic behavior, or it was a problematic behavior at some point, and about 2 to 4% of women. But it doesn't mean they really meet any of the criteria presented in ICD, this is just self-declared problem, self-diagnosed problem. So let's see how we can diagnose the problematic use of pornography or other sexual behaviors, and here we have the diagnostic guidelines just presented by Mark, so I won't go into the details, because Mark just mentioned them, but basically when we look at them, we have a lot of similarities and those are the red points to gambling disorder, or gaming disorder, or other addictive disorders, so it's a loss of control, neglecting other important areas of life, unsuccessful attempts to reduce the behavior, and severe consequences and continuation of behavior despite those consequences. The only difference here is that this behavior doesn't have to last for 12 months, 6 months is enough to recognize that, and here we have one extra point marked in blue, that the distress, which is entirely related to moral judgments and disapproval, is not sufficient to meet these requirements. And it will be important when we look at the conceptualizations of people seeking treatment. Okay, and right now we have a few relatively new screening tools everyone can use, they are available, and as an attachment to appendix to the papers mentioned here, and especially those three are interesting because they are short, so it's relatively easy to use them in the clinical practice. The newest one is Compulsive Sexual Behavior Disorder Scale, there are two versions of it, 19 items, and short version 7 items, it has been validated across 42 different languages, sorry, 26 different languages, 42 different countries. Compulsive Sexual Behavior Disorder Diagnostic Inventory, 9 items, also available in multiple languages, and Brief Pornography Screener, developed by Shane here, it's only 5 items, and this one is particularly related to problematic pornography use, it's also available in a few different languages, and it has been also validated in the longitudinal studies on the clinical samples, we know that it's very sensitive for improvement and changes during the treatment, so it's a really nice tool. Okay, so let's briefly look at those questionnaires, here we have the Compulsive Sexual Behavior Disorder Diagnostic Inventory, there are 9 items, and 7 of them are related to the diagnostic criteria from ICD-11, but there are 2 extra items, which are related to the self-regulation, so we, as you can see, the diagnostic criteria in ICD-11 don't mention mood regulation or using certain behaviors to regulate stress, to cope with stress, but we know that for some of the individuals, this is quite important behavioral function of engaging in compulsive sexual behaviors or problematic pornography watching. So sometimes it helps to measure them and this inventory includes these two items related to stress and mood regulation. Brief Pornography Screener also has such an items. Out of two out of five also measure self-regulation. And coping with pornography. Okay, we were trying, okay maybe first. How many naked bodies do you see here? Does anyone see more than two? Please raise your hands. Okay, anyone see more than four? Oh, there is one. Okay, what about three? Okay, so you had a really good night. So, we were trying to develop the projection tests but it doesn't work. No, it's just a joke. It's a logo of our research project. Okay, let's come back. So, just stick to the questionnaires for the clarity. What are the brain mechanics of the problematic pornography use? So, according to the results of right now, there is over 20 fMRI studies available with the problematic pornography users and people with other compulsive sexual behaviors. Very often other compulsive sexual behaviors are related to compulsive use of paid sexual services, engaging in risky casual sex, and very often also we see the chem sex. So, it's a use of mostly stimulants to enhance sexual experience. But problematic pornography use consists about 80% of individuals who are seeking treatment because of CSBD. So, majority of studies right now with neuroimaging, those studies were conducted mostly with those people who struggle with problematic pornography use. And this is important to keep it in mind. And right now there is almost 20 of such studies available, not all of them with individuals meeting the criteria, sometimes with subclinical samples, but these are our studies with individuals who really meet the criteria of CSBD. And here what we learned from these studies is that we see hypersensitization of the dopaminergic circuits, reward circuits, and this is mostly related to increased reactivity of the ventral striatum for cues predictive for erotic rewards or pornography, and not for cues related to monetary rewards. So, as you can see those green bars, here we have the response of the ventral striatum for the monetary cues. They signal the chance to win some amount of money. And both groups, problematic pornography users, the solid bars and control subjects, the striped bars do not differ in terms of the reactivity of ventral striatum, but we have significant difference when we look at the red bars. Those are the erotic cues. And here, this difference is significantly related to the severity of symptoms, which you can see at those scatter plots below. So, if there is higher reactivity of the ventral striatum for the erotic cues, and there is more symptoms, and in our studies we had individuals who were able to watch porn, sometimes they were watching porn for up to 15, 16 hours a day. It was accompanied by the 13, 12 masturbations a day. So, you can see that sometimes it may be really severe behavior impairing other life activities. And we can ask the question, what was the first, chick or egg? Are those differences in the brain reactivity precede problematic pornography watching or the results from pornography watching, frequent pornography watching? And to answer these questions, we conducted a longitudinal study. It's also a clinical first, double-blind, randomized clinical trial. Relatively small one, it was a pilot study. Right now, we are starting a new, much bigger study where we used placebo, paroxetine, and naltrexone. It was inspired with the previous observations of the gambling research, and also similarities in the neuronal mechanisms related to the hypersensitivity of the ventral striatum, or the frontal cortex, and other brain regions which were previously also reported in gambling disorder or substance use disorders as hyperactive. And here in this study, we conducted an fMRI measurements before treatment and after five months of treatment. What is interesting is that all three conditions, all three groups improved. So the placebo is as effective as paroxetine and naltrexone. But some of them, like paroxetine, leads to a higher decrease of the ventral striatum, striatal reactivity. And here, those yellow spots, they represent the amount of the decrease of the reactivity. So we can see that this mechanism of hypersensitization can be reversed after five months of treatment. So it's rather a cause than, it's rather an effect of problematic pornography use than something what is preceding the problematic pornography use. Okay, so as we can see, after three to five months of treatment, we can reverse those hypersensitivity mechanisms in terms of compulsive sexual behaviors. And here, when we look at the functional data, we see similarities between problematic pornography use or compulsive sexual behaviors and addictions which are related to higher sensitivity for erotic use. It's similar mechanism to other addictions. And this sensitization can be decreased after successful treatment. Okay, so the next question is, can anyone develop problematic pornography use? And here, we don't know that for sure because there is no longitudinal studies yet. Probably very soon, we will be able to analyze the data, look at the data from ABCD studies. However, the pornography use and sexual behaviors are recorded only from the later age of the participants, when they are teenagers, not when they were kids. We know from our research that the average onset of pornography watching these days is around 10 years old. And about 25% of boys and girls watch on monthly basis at the age of 10. So this is something that we also need to keep in mind that those behaviors starts pretty early. And with the computer games, I think it's much earlier these days with gaming. So coming back to the brain structure, we conducted a study when we were comparing compulsive sexual behavior disorder with healthy controls. And in the same study, we also recorded data from individuals with alcohol use disorder and gambling disorder. And we see some similarities in the lower volumetri of the prefrontal cortex. It's all mostly orbitofrontal cortex, as well as the lower volumetri of the anterior cingulate cortex. And this is related with the severity of symptoms of compulsive sexual behavior disorder. We don't know if those differences in the brain structure are preexisting or is it a result of problematic behaviors. But those are exactly the same differences as we see in other behavioral addictions. So this is the next similarity between CSBD or PPU and addictions. Okay, so now let's look at the different subgroups of individuals who are seeking treatment and how we can help them. So one of the subgroups are individuals with hypersensitization. And usually they are characterized with the high sensation seeking. So they are seeking for novelty while they are watching pornography. There is an evolution of the content they are watching. Very often they are not only sticking to pornography watching, but they are also seeking the real life, paid sexual encounters or casual sexual encounters where they can act what they've been watching in the pornography. And you can see that there is this high novelty seeking aspect. And also there is a lot of sensitivity for cues, stimuli, situations associated with previous pornography watching. So there is plenty of triggers which leads to uncontrolled pornography use or other compulsive sexual behaviors for them. And here most common use modality is cognitive behavioral therapy right now. And it's focused on the functional analysis of the behavior. For example, pornography use. What's the role of this behavior? Does it help them to regulate their mood or cope with stress and so on? Then it is very important to identify the cognitive distortions. Very often there is a dichotomic thinking. There is a lot of distortions which leads to higher levels of anxiety like mind reading, like catastrophizations and so on. They have also plenty of dysfunctional beliefs which enhanced anxieties and stress. And we try to help them develop also healthier coping strategies. And what is also very important is to help those individuals to develop healthier sexual activity. And very often, for example, masturbation without porn is a good outlet but many of them almost never experienced that since the very early age. They were always masturbating with pornography. When we have individuals who have problems with paid sexual services we try to help them develop more meaningful relations and so on. So we try to find the healthy sexual activity which can have less risk of compulsivity. Then the mindfulness-based relapse prevention training is also helpful for this group. And here we try to help those individuals to develop metacognitive skills, to be able to watch their thought process, identify their beliefs and be more aware of their emotions and so on. And it helps them to cope with the variety of difficult emotional states. And also in this group, what is specific for this group which is not typical for other subgroups I will present in a few minutes is that we also focus on the triggers identification, craving management and relapse-related beliefs. With the mindfulness-based relapse prevention trainings we can also focus on the craving surfing. We are in San Diego so craving surfing sounds pretty cool here. But yeah, it's also a useful strategy. For some of them the 12-step based programs are also helpful. And we know that the SSRIs and naltrexone may be helpful as well. Then let's look, before I introduce two other subtypes, let's have a brief look on the individuals who are seeking treatment for problematic pornography use. And here we have two dimensions which we can assess during our clinical interview. One is the frequency and duration of the problematic pornography use. And we know that there is some relation between how often and how frequent ones engage in the problematic pornography watching and treatment seeking. But we know that this relationship disappears when we take in account the negative impact this sexual behavior has on one's life. So this is very important to not only look at the frequency and duration of sexual behaviors but on the impact on one's life. And this impact can be enhanced by the severity of dysregulation measured with those neuronal mechanisms I've been presenting before. And here when we have these two dimensions how severe is this impact on one's life and what's the frequency of the behavior and duration of the behavior. And then we can see different subtypes of individuals seeking treatment. We have a lot of people who are self-reporting problematic pornography use. But only some of them really meet the CSBD criteria. We are still waiting for the results of the field trials to see how many of them. We don't have this data yet. And the individuals I've been presenting here with the hypersensitization, those are individuals who usually meet at least three of those criteria. So we don't know how those brain mechanisms look like among others. So this is probably heterogeneous group. And a lot of those people may not have such strong changes in their neuronal circuits. Some of them do not report this very strong hypersensitization. And they don't also report any evolution of the content they are watching or engaging in more risky behaviors and so on. But what is the main mechanism for them is emotional dysregulation. So not everyone has this hypersensitization probably. Many of individuals seeking treatment may have only emotional dysregulation. And we can see in our studies that a lot of people have higher level of depression and anxiety. And very often the pathway here is quite simple. There are some difficult situations which leads to difficult emotions. And then they try to cope with those emotions, strong anxiety or loneliness or other things with pornography watching as a distractor. But then they start neglecting other areas of life or they have some decrease of the mood because they spend too much time on pornography watching. And there is more difficult emotions and we have a vicious circle. And we know that for a majority of people who are seeking treatment, the decrease of mood is the main reason. Then the second in line is some negative impact on the social relationships. Then on professional work. And then on family life, education and health. So this emotional dysregulation group can benefit a lot from the cognitive behavioral therapy. And here we have exactly the same methods as I presented before. They just break this cycle, this link between difficult situations and difficult emotions through the restructurizations of cognitive beliefs and cognitive distortions. And it's easier for those individuals to cope with their reality without compulsive sexual behaviors. So that's how it works here. And there is a third group which is quite interesting and also important. Those are individuals who struggle mostly due to their moral incongruence. And this is the group who usually has much less frequent sexual behaviors than others, but they still claim that this is a big problem for them and some of them are seeking treatment. And this is due to some very strict moral beliefs that, for example, they shouldn't watch pornography at all or they shouldn't have premarital sex, for example. It's very often related to religious beliefs. And here, very often, the mechanism looks more or less like that. There are some sexual needs which are met through masturbation and pornography use or some other sexual behaviors which leads to the feeling of incongruence between the behavior and one's beliefs. Then it leads to some guilt and shame. Then the coping strategy with guilt and shame is more pornography use. And then there is more guilt and mood decrease and we have a vicious circle here. Then, very often, they engage in some religious practices, reducing the guilt and shame. And it helps them abstain from the behavior for a few days or sometimes a few weeks. And then we have the repetition again. So we have two vicious circles here. And it's important to help them to break those circles. We know that this incongruence can also enhance the subjective feeling of the negative impact of one's sexual behaviors on his or her life. And here, very often, the acceptance and commitment therapy is helpful. So we try to help those individuals find the accepted ways or frequency of sexual behaviors, pornography use, or accepted sexual behaviors to break this moral incongruence aspect and the guilt and shame. And then very often cognitive behavioral methods are helpful here to help them identify cognitive distortions and dysfunctional beliefs about their sexual behaviors to break this aspect of the vicious cycle. And sometimes we can include clergyman, priest, pastor, rabbi, imam, or others. Usually we don't need to work with them directly. The patient can just talk with their clergyman to explain how it works and reduce the dichotomy and change a little bit the way how they engage in their religious practices so it's not compulsive. It's more on the regular basis, for example, it's very important. Okay, so that's it. And at the end I'll be happy to answer all the questions and discuss. And now it's my pleasure to introduce Shane Krause. Shane is a professor at the University of Nevada, Las Vegas and the best place probably to study behavioral addictions. And he's one of the leading scientists in the field of CSBD and also other behavioral addictions. Thank you. Thanks. All right, cool. Thank you. All right. All right. All right, okay. Okay, so it's kind of nice to go last because they did a lot of my slides already for me so this is fantastic. So we're gonna have some time for, we're gonna have a lot of time for questions. I know you'll have access to these slides so a lot of them have links to get things, resources, papers, or scales. So I want you to take away the importance of screening and we're gonna talk about that. But really quickly, so how many by show of hands have treated someone for gambling disorder? I'm just curious. All right, oh, yeah, of course, yeah. How about compulsive sexual behavior, sexual addiction, something like that? Oh, wow, this is, okay. Okay, cool. Normative trainings and there's like one hand goes up. All right, I'm gonna get started. So these are our learning objectives here. So again, we've kind of already done this here. We talked about behavioral addictions, what are common co-caring psychiatric issues? We're gonna talk, but the biggest thing we're gonna talk about a little bit more about screening tools for gambling and sexual behavior. Dr. Gola did that, but we're gonna talk a little bit more about that. I'm gonna kind of really go through the psychotherapy and psychopharmacology because they already did amazing work on that, which is great for me. But I'm gonna mention some stuff we're doing with veterans. How many people here are working with veterans or in the VA? Okay, awesome, wonderful, yeah. So we're also doing work here with our Las Vegas VA. So prevalence is an issue. Just really briefly, the word compulsive sexual behavior disorder has kind of been over time has changed originally with sex addiction and hypersexual disorder to compulsive sexual behavior disorder for inclusion. Prevalence has been really challenging, right? So old suggestions were 3%. There have been other national samples where they found 8%, but they actually didn't ask the people why they were distressed. So I thought it was interesting. We've done our own work here as well and found higher rates, 11% for males for pornography and 3% for women. So we really don't have great prevalence. We're working on that. We really need this. This is something that's necessary, I think, for field trials, which we mentioned. But again, I think it's important to say that it is out there. The fact that so many people raise hands here tells me we're seeing it and we should be asking about it. So lifetime is probably, interestingly, those with OCD that found about 5.5% is a German sample and again, higher for men and women. Interesting. So again, I think it's something to keep thinking as we're gonna do more research on prevalence. So as the reason we talked about pornography is because it's prevalent, it's super common, super available. I think often people seeking treatment are coming in for pornography. I would say, since some of these early papers, we are now doing work on Grindr and sex hookup apps. So how many people here have ever asked their clients if they're using any online apps for casual sex or hookup sex? Anyone? Okay. So we're seeing that. We have some papers forthcoming on that. I would definitely be encouraging to ask about that. That's on here, but I think that will be on this list in the future as well. So I like to think about it. So we have risk factors and what are protective factors. Sorry, I mean, it's kind of small. Risk factors are generally things can be potentially like personality, could be genetics, it could be your physiological stuff. Protective factors, but also could be risk is family, partner support, social support, social network, environment, could be both ways. So all of these things kind of lead to CSBD. And this is similar to addictions. It's complicated for lots of people, but again, it isn't one path. But they all, the combination, I think, does contribute to CSBD. And but we also are lacking longitudinal data, though we are collecting it as we speak. So the big takeaway is psychopathology. So you need to expect it. If someone has, how many people treat people with mood disorders, anxiety, ADHD, PTSD, and trauma? Probably everyone here, yep. So you better be screening. If you're not screening, you know. Oh, yeah, absolutely. So we should be screening. So this is a screener that we developed a couple years ago. It's a CSBD-19. It's a 19-item scale. It was initially validated in four countries, including the US. It has a 50 points as a cutoff score. It is, we've used it for a number of studies. It's been psychometrically helpful. So in a sense, it's 19 items. I give this out often like in waiting rooms or you could just use this as an intake. It's a little longer. There's a shorter scale. But recently, we knew that just testing in the US, Germany, or overseas isn't good enough. So there was a 42-country study, 26 languages of the scale, that's now published and publicly available. And when you click on this link below, it says 26 languages, you will find all of the 26 languages, including many of them. So it's helpful. But just take away here 4.8% of the people we asked were high risk for CSB in our sample. This is a sample of 82,000 people in the world. Country and gender-based differences were observed, but there were no sexual orientation differences within CSB levels. 14% of individuals with CSB had ever sought treatment, so it's pretty low. And 33% had not sought because of various reasons. In a sense, very few people get help, even though, again, 5% is pretty big. I mean, that's definitely something to think about. There is the 19 version and the seven-item. It's a seven-item screener. And I would recommend, if you wanna screen or do research, these are both available publicly and easy to include. And they both have cutoff scores as well. And if you click on that, you'll get more information for it. So this is a scale that I made actually in the West Haven VA and also when we were at Yale. So we started in the VA with it. Which we're very proud of. So this was the Brief Pornography Screen Scale. It's five items. It has been used initially, was studied in many countries, or a few countries. But we've also expanded this to 26 languages and 42 as well. So this was helpful. This also has, let me see if I can show it to you. Here it is, sorry. I'm mistaken, that was a mistake on the slide. I mean, these are the items here. You find yourself using pornography more than you want to, having attempts to cut back, finding it difficult to resist urges, that's craving. Finding yourself using more pornography to cope and continue to use even more when feeling guilt. So it has a cutoff score of four or higher. So it's scored zero, one, or two. Clinical samples have generally a score in the six range. But this has been used in clinical studies, including randomized clinical trials. And it's been shown to reduce with effective treatment. Right now we have a paper out. It's very close, we hope, to being published. The BPS as well with other measures. Again, 42 countries, 26 languages. Again, we're seeing about 3% of our participants. Gender differences, men are higher. No sexual orientation differences. And again, very few people seek treatment. So again, I just recommend this if you're, actually let me ask you this. How many people are screening in their clinic for pornography? Yeah, woo! Yeah, that's awesome. Okay, so how many are gonna screen when they leave here today? Oh, come on, all right, I'm not selling it enough. Okay, so definitely consider screening for it. I think it's something, you know, and I think we're uncomfortable to be asking about this, but I think it's something that an intake you could actually ask about, okay? So we already mentioned this. They did a great job with this. Psychotherapy is effective, it does work. Acceptance and commitment therapy act is helpful. CBT also works. Mindfulness-based approaches are helpful as well. MBRP is one of them. Dr. Gola's group did some work on that as well. So again, I think also DBT skills have been useful across for behavioral addictions and other behaviors. So treatment does work. I think it's also important to wrap in treatment that addresses multiple behaviors, not just CSB or pornography. Psychopharmacology, we kind of went through this already. I'm a big fan of naltrexone, so I'll just tell you that right now. Full disclosure, I think it works helpful, particularly for those with craving and pornography. We've published on that as well. And again, Dr. Gola discussed this randomized clinical trial study with pradoxine 18 and naltrexone, which again beats placebo. I think one thing to think about that's really important is that gambling and pornography and CSB have high placebo rates. So it's really interesting that people feel better when they're doing something. And I think that's something you need to think about. And why I'd recommend people getting therapy, group therapy, things like that. So acetylcysteine as well has been shown to be helpful. There's some stuff on that, which I think is interesting. Seems like it beats placebo. Seems like it's a greater placebo than anything, but it's successful. So special populations, what do we not, we have a lot of gaps here, right? So we don't really have a lot of information on women. We do not have a lot of information on ethnic and racial minorities, gender and sexual minorities, older adults and individuals with disabilities. So up until recently, most of our data has been what we call white, educated, industrialized, rich and democratic or weird. Yeah, right? You like that? I didn't make it up. But now, so recently, but what's nice is that with some of these larger studies that we mentioned, the International Sex Survey, right? With so many countries, we're finding that there are concerns everywhere in the world, right? And that's kind of what we'd expect, right? So we wanna make sure we're using tools that are culturally valid and languages that reflect people. And so far, we're doing that, which is helpful. So I do work in military. Some of our work earlier back in West Haven, and as well as Anil, was looking at veterans. So we actually looked at combat veterans, what we call OIF, OEF, OND. And we found high rates, about 14% of the male veterans screened positive for CSB. And that was associated with gambling, higher gambling, suicidality and STIs. Again, so one of the, I think we were one of the first people to do a paper looking at hookup or kind of social media to meet someone for sex. So this is 2017. Again, we found veterans, higher rates of doing that. And they were also having other higher levels of psychopathology, right? So thinking about if someone's having a lot of risk behaviors, PTSD, insomnia, substance use, how are they, what kind of sexual activity are they doing? And is it being facilitated through online? And I would say it is now. I think this is definitely a little bit older, so it's changing. Again, we've found, we've been publishing some work before on veterans and substance use or alcohol use disorder and hypersexuality, very high rates, of course. So yeah, so I think veterans are a risk group that you should be looking at. And VA, I think we're not, we are talking about it, but I think we're not actively screening the way we should. Okay, so gambling. So Dr. Potenza discussed this. I'll kind of blow through this really quickly. So people love gambling. People love the lottery. In Nevada, we don't have the lottery, but people will drive an hour to get to the border to buy a lottery ticket, which I find interesting. So prevalence is pretty low, about two to 5% for problem. That means sub-threshold, although higher rates for college students, young adults, and veterans are 3%. So if you say, well, what's the most highest prevalence for gambling disorder among groups? It's gonna be U.S. veterans, so it's generally three to one. So, and unfortunately, those most with problem gambling don't recover without help, okay? So as we already mentioned, there's high psychiatric comorbidities here with gambling, mood disorder, substance use, so on, PTSD, personality. Gambling really does reduce quality of life and functioning, it's quite bad. I mean, many people, when they come to see us, have really, are experiencing bankruptcy, many losses, interpersonal issues, lots of rates of suicide. Our own work also, high rates of substance use among veterans, alcohol, cocaine, opioids, and cannabis. So veterans might be seeking treatment for these things, alcohol, you know, cannabis, opioids, but we're not screening them for comorbid gambling, and what we know is that we need to treat double trouble. We have to treat both concurrently to have success, and we're not. So, also take away for veterans here with military, 40% of ones that he found reported past previous suicide attempts, so again, we should be screening. Same thing here for community-based samples. Here's one of 10,000 in Massachusetts, and they found about 10%, less than 10% were veterans, that's about right, but of that group, you know, you have 20% for kind of problem gambling. So again, higher than it should be, and also again, among 400, recently we published a paper on the Cleveland VA, on their data from their program, and of the 401 US veterans seeking treatment, 41 had comorbid PTSD, 31% substance use, 20% mood disorders, and you know, at least, almost 75% had at least one other psychiatric disorder. So they really have psychiatric disorders in gambling like bananas, they come in bunches. The issue is we're not screening for gambling. We're treating the PTSD, not recognizing that the gambling might be a way to cope with PTSD. So again, here's some more on military really quickly. We did a study, I'm gonna show it to you later, or actually, Dr. Bertinza did a study. So I did one in primary care, which was 2% we found, we screened, and they also screened about 5% for nationally sampled veterans. And again, when someone screens positive here, we're seeing a lot of issues in terms of rates with issues, so, and we're also seeing higher rates of gambling among women veterans and civilians as well, so something to think about. I'm gonna keep going here. Okay, so we're doing a lot of sports betting research. So how many people live in states that have legal sports betting? Let's see, okay, cool, okay, yeah, yeah. So how many here are asking their clients or their patients if they're doing sports betting? Like, okay, nice, oh, okay, okay. How many think they should be asking about sports betting? Yeah, okay, cool, yeah, okay. So sports betting is really hot, everyone's doing it, you know, it's like everyone's beyond the party right now. So defining, so sports betting is something that we need to be thinking about. It's a form of gambling, it's growing billions, you know, I mean, I was just telling people earlier, Super Bowl Sunday was $15 billion was wagered in one game. It's big money, and yet there are risk factors, and those with sports wagering issues have more problematic issues relative to other gamblers. So this is from a paper we study, we published in Comprehensive Psychiatry recently here. So you can see, this is the percentage of persons who gamble in sports wagering. And what I kind of, I don't have a pointer, but what I want you to know is that, so you can see there's a couple groups here. There's a low, you see the low risk, moderate risk, and the high risk. So red is the, blue is the high risk. And what I want you to take away is that the more someone gambles, the more activities, the greater the risk. So look at four activities, you see a lot of blue, right? So when you speak with someone who's sports wagering or sports betting, or has multiple, you know, I love Keno, I love lottery, and lots of things, I want your ears to burn on fire, to really be thinking around more increasing activities, particularly around sports, those who do sports wagering, because it's really a risk factor. Again, same thing here. So what we did, we looked at risk level. So we're looking at no risk, low, medium, high. So high risk is the far right. And what you can see is the risk factor, risk goes up as they do more things, right? So if someone's wagering as a sports gambler, but also does lots of different sports wagering strategies, their risk goes up for having actually problem gambling, as you can see. And for high risk, it's 34%, so. Okay, so something to think about. Same thing here, substance use. The takeaway here is that we looked at this and said, well, is sports wagering behaviors related to substance use? And we looked at different substance use, and across the board, the answer is yes. And here we have alcohol, tobacco, THC. You have prescriptions, illicit pornography, you know, gaming as well, across. And you can see, we looked across the types of sports. So traditional sports wagering, fantasy, daily fantasy, eSports, we kind of crossed the board. So, yeah, so it's interesting. So I think it's one of the things that people who have, who are engaging in sports betting, even problematically, there is co-occurring substance use, and which we should be thinking about as well. So a screener that I really like that, actually, how many of you have seen the Brief Bisocial Grambling screen? Anyone here? Okay, awesome. So this is a three-item screener. When you click on this, you'll get access to it. We've studied this in primary care. We did a study, and we were able to screen with it. Takes maybe not even a minute. If they say yes to any of these questions, you want to further screen for gambling. In primary care, this worked really well. We trained nurses and doctors to do this. It was not a problem. Again, we just screened randomly every person who went through primary care clinic, and we got 2% who screened positive, which seems pretty low, but those are all people who had never been identified nor disclosed a gambling problem. So things I think really important to you to do, rather than just say, you don't have a gambling problem, do you? That's not helpful. Something like, what do you like to do for fun? Do you have any concerns about your gambling? Hey, has anyone expressed any concerns you have? So sometimes people will say, well, I'm having issues paying my rent or money issues, and I'll go, oh, okay, tell me more about that, and that will clue me in to say. But again, really be careful to kind of, when I'm training a lot of people, they'll say, oh, we have to ask about suicide, and they'll say, my students will, you don't have suicide issues, right? And it's like, no, no, no, no, redo it. So same thing, be careful about your phrasing. Create space, think of the stigma that particularly a lot of people have disclosing gambling in our society, particularly women and other groups. So we really wanna create space here for this. Other tools that we use as well is the Problem Gambling Severity Screen, the PGSI. It's a nine-item self-report. It has groups, non-problem, low-risk, moderate, and high-risk. So those with eight or higher are generally what we would think about those with a gambling disorder. These are other tools as well, but I really like the PGSI, so if you're doing research, I'd encourage you to do it. In your clinical practice, I would encourage you to do it. Again, if you don't have a lot of time, use the three-item screener, it's pretty useful. And again, these are other questions you could have, you know, asking people here as well. So gambling, just like CSB, does work. I think CBT has been helpful. We talked a lot about this already, CBT, brief psychotherapy, education. Sometimes you only have to have a conversation around someone's, how they spend their money and what's useful for them. And sometimes people realize, wow. Like, for example, I had someone, I said, well, how much are you spending on lotteries? And I don't know. And we went through and it was about $500 in a month. So he realized, wow, that's more money than I thought it was, right? And right there within 30 minutes, we started doing intervention. So recovery, I'm a big supporter of recovery programs, GA, 12 steps can be helpful. We know that those with dual diagnosis are really problematic. They're hard to treat. So I really, we've been doing more work for ourselves and gambling around mindfulness-based relapse prevention. You've heard about that here as a kind of a trans-diagnostic treatment to treat lots of things. Again, if you're only targeting one problem, you're probably not gonna get it because if they have lots of issues, you need to treat all the issues or maybe stabilize PTSD first than do gambling, for example. So this is a manual that's available to you. It's free, it's available. It's from Canada, it's great. It's an MBRP protocol that was developed for gambling. We are currently adapting it for VA with a study in Las Vegas, but it's available. It even has a whole, lots of exercises with yoga poses. It's awesome, it's cool. Can't do the yoga, but everything else is great. So it's really useful. I think it's, if you're doing group therapy or having a treatment program, I would definitely recommend you use that as well. Really, really briefly, so psychotherapy or psychopharmacology, as we discussed earlier, there's no, a couple years ago, we did a systematic review. If you click on that, you'll get access to it. And what we found, more or less, was, oh, I went too far. There really isn't a gold standard, as I mentioned, although naltrexone does seem to be helpful. I think the issue with naltrexone, the old studies, was higher doses, which causes side effects in people with taking it. So I'm more interested now in Vivitrol, particularly with those comorbid opioids, and that's something we're doing in Las Vegas. But again, I think it's really important to think about what are the comorbid conditions to treat and to medicate. But again, most people, I think, with a gambling disorder, would not look for psychopharmacology treatment. I would refer for psychotherapy or for some kind of social support first. So naltrexone's been shown to be useful, as we mentioned earlier, but again, it's not a gold standard. So, yeah, I think we'll stop there. Okay. Thank you. So we have time for questions for any of the presenters. Yeah. All right, so. Thanks a lot, Dr. Potenza. I've really appreciated your leadership over the years in the area of behavioral addictions, pathological gambling. David Crockford from Calgary. I had a question. One thing which didn't come up is that clinically, when I see stimulant users, I always have to ask about sex, and you didn't talk much about that. I know certainly meth that they end up using, Grindr, to actually access it as well, and it seems to be same sex. There's cocaine. I always have to be asking about their sexual activity. Can you maybe talk a bit about that? Okay. Yeah, so yeah, we actually just did a study on Grindr as well. So I think, so you have to tease apart. So yes, we're seeing, so we found, we did a study recently and found about 20, 30% CSB on the Grindr, the study, and we found about 10% stimulant use within chemsex. So I think what is important is to try to stabilize the stimulant or the substance use and see if the sexual behavior is happening outside of that. For CSB, it has to be independent of that. So if they're only having sex on a stimulant, which is very common, I would treat that high-risk behavior in the context of substance use. I wouldn't assume that it's an impaired control outside of sex itself. I think they can happen, but I think it's very common, and I think it's increasing right now. We're doing, yeah, it's quite. Did you? Yeah, I can add also, you can also ask about the history of the behavior. So very often when I ask patients how it looked like before they started doing both things together, using stimulants and engaging in sex, many of them, actually those whom I see, say that they already had some problems with the compulsive sexual behaviors before. At some point, they either started engaging the chem sex to reduce the shame or guilt in the MSM community, for example, or just to enhance the experience because it wasn't enough, and there is the sensation-seeking hypersensitization mechanism. So this is important, and sometimes it's just other way, that someone was using stimulants and then discovered that sex feels good after. We'll switch back and forth to the sides of the room. Jim Halicus, a whole bunch of questions. Did you look at testosterone levels before and after treatment, and changes in testosterone level? What about looking at isolation and anger with increasing levels of sexual use? You know, the pornography. And what about inverse relationship to sex with the partner? That's how I identify it, is when the partner complains that the man is in the next room and she's naked waiting for him. And then, what about association with positive family history of alcoholism in first and second degree relatives? And then, too. Yeah. This will be a memory test. Yeah, so maybe I'll just need to mention that since I became a father last week ago, my watch tells me every day that my cognitive function is impaired today. So let's try it one by one, yeah? Testosterone levels before. Yes, yes. So yes, in our clinical trial, we were measuring testosterone. There was also a trial in Sweden. It was open-label trial with Naltrexone. They were also measuring testosterone level. And first of all, we don't see any differences between that in testosterone levels between controls and CSBD patients. And there was no difference between before and after treatment. There are the Sweden group by UC Okina, they showed the difference in oxytocin level. And I'll add to that point. We did a study in Israel looking at both oxytocin levels and arginine vasopressin levels, which has more of an aggressive effect oxytocin, oxytocin more prosocial relationship. And what we found in about 100 individuals with problematic pornography use was that the strongest relationship was with psychopathology directly relating to pornography-related hypersexuality. But there were also a direct pathway for arginine vasopressin, so more aggressive behaviors. But also there was an indirect effect where oxytocin levels operated through decreased empathy to link to increased hypersexuality related to pornography. Well, the decreased empathy goes along with the question of isolation with increasing pornography and antisocial thinking or violence thinking. Yes, however, very often when you look at the history of the patients, we don't have many longitudinal studies. The social anxiety may be rather a pre-existing problem. So the pornography is the relatively safe outlet for meeting sexual needs, seeking excitement and so on. But then, of course, it only makes this isolation deeper and anxiety deeper. The other thing that I would add to this, which I agree with your points, is that an area that I think is a research gap is to understand the types of pornography that people view with respect to the relationships to specific behaviors. And some of the people who I've seen in treatment have mentioned that it's kind of like going down a rabbit hole where there are nudges on the internet on pornography sites. Well, if you've liked this, try this. And they feel like they're being exposed to more extreme versions of pornography that are often more violent or into more unusual behaviors. So this is an area that I think we need to understand better with respect to the types and patterns of pornography use in which people engage. Yes, and here I can add one more thing. Thank you, Mark. We were also studying those binging pornography watching behaviors where people masturbate multiple times a day and watch pornography for multiple hours a day. Sometimes just they describe it as edging. So they try to not reach the orgasm for a few hours and just keep watching pornography as long as possible. And here, usually during those binges, people describe that they switch to new content, something more extreme because the 10th Climax during the same day is hard to reach. With the old porn, they need to watch something more extreme. Three brief suggestions, and then I'll sit down. One is, you mentioned the hypersensitization. Whenever I hear that, I think of the anticonvulsants. And I think that whole category of medications needs to be looked at to see what efficacy they might have. Also, the paroxetine arm was weak, but it had a signal to it. With OCD, fluoxetine needs to be at 120 milligrams rather than at 20 milligrams. It may be that the paroxetine has to be moved up considerably. And another thing is, I think hoarding is gonna move into the addictive disorders from the compulsive disorders. Hoarding ought to be looked at. Mark, maybe you can. Yeah, so one of the things about paroxetine, and this is a set of case series that Mateusz led the communication on, is that in the individuals with problematic pornography use, the paroxetine in three cases was associated with decreased pornography use, decreased anxiety, but also the emergence of other new compulsive sexual behaviors not related to pornography use, like paying for sex and extramarital relationships that were egotistonic and relationship-harming. So I think it's important to keep this in mind when advancing the dose of the medication, that one needs to take a thorough history of the potential outcomes or relationships, impacts that it may have on a range of behaviors. Yes, and there is a paper by Pierre Brican in Nature. Oh, gosh. Oh, okay, anyway, you can find it. But he basically applies this dual model, dual sexuality model to CSPD, where it's important to remember that there are excitation elements, this novelty-seeking, pleasure-seeking in sex, and also some inhibitory mechanism, like anxiety of performance and other things like that, and we need to cope with both in the treatment. If we just disinhibit patients very easily, removing the anxiety with too high doses of SSRIs or other things, then this excitement may take over. And the anti-convulsants as an area, using anti-convulsants as a treatment tool. Anti-convulsants, mood stabilizers. The mood stabilizer, I don't know any study. No, I'm suggesting it as a possible. Maybe Shane knows case studies. They've done a case study, I think, with Topamax, right? Yeah, I don't think it's been well-studied. The issue is with ant side effects. People often don't want to take medications because if it causes other sexual side effects, too, so that's an issue. Lomotrigine or Depakote or carbamazepine. Topamax has been the one that has been tried the most because that was pushed by the company in this area. But the older ones. Warrants consideration. Thank you. Ken Rosenberg from New York. Great presentation, thank you so much. Very simple, quick question. My patients do their online poker, their pornography on their phones. And when they get their phones alone, which is how my patients get discovered by their spouses. What technologies are you suggesting? What apps are you suggesting? There's a couple of things, NannyGate, that have been around. But if you could give us some pearls on exactly what we could do. What's the kind of thing that blocks the online sites? Thank you so much. So I would think about, we think about what's called a behavioral functional analysis. So the thing is, is most people who use porn or do certain things do it in very specific places. So it isn't actually random, it's very certain. So once you know what time, if it's a time or place, what you do is then create a plan. For example, so those who have spouses, you can have their apps that will send your history to someone else, it's great. But what we did, we've done with couples, is literally at seven o'clock at night, they come home, they turn off the phone, they give it to the spouse, and it goes away. Because what we found is they use pornography in the bathroom at nine to 10 o'clock at night, very specifically. So we eliminate that. Because often with spouses, they're not having sex, they're not working, so what we have to do is eliminate that stress, engage them in just positive things, non-sexually, and then really engage that sexuality as we kind of shape the behavior. But I have people move their computers to the living room. Because in a sense, part of it is people have lost that ability. So I do a lot of behavioral things, and those are really successful, and they work well. Okay, so there is multiple apps to block the adult content. Even in the current versions of Android system or iOS, you can set it up in the screen time, for example, in iOS. It's relatively easy to set up. Whenever you access the adult content, either gambling content or porn, you need to provide a password. This password can be set up by someone from your family or your friend or whoever, and this is helpful. However, I always compare it to this bowling experience. When you go to the bowling alley and you start playing, your ball can either go too much to the left or right, and then you won't hit anything. And the left one is to just succumb to your craving and go with the flow and start watching something. And the right one is just focus on blocking. And what is very important for patients is to learn the middle way, to really stop, pause, and say, okay, now I have this craving. Where does it come from? What do I feel right now? What are my genuine needs at this moment? How I can meet them better? What can I do? And this is helpful because we have also recently, there was a published study showing that those individuals who focus more on blocking, they actually spend more time on watching. And paradoxically, they may not watch as frequently, but then when they have strong craving, they focus on how to remove the blocking software and then they have longer binges. And it happens. But I think oftentimes in, say, problematic pornography use, there is a lot of damage to relationships and lack of trust that needs to be rebuilt. And there are some programs or apps like Covenant Eyes that allows for a partner, for example, to view or intervene or control digital devices when viewing pornography, for example. And so this can be used as people find that middle road, that middle area of the bowling alley lane to help build trust as well as get to the place where you can take off the guardrails. Oh, hey, there. Dave Atkinson, I do adolescent addictions. One brief comment and then one question. It's like, the first thing is I think historically, like the prohibition of pornography has been kind of tied to religiosity. But among young people, there seems to be a growing broad-based recognition that this isn't really good. I mean, you're talking about from fourth wave feminists to, I don't know, reactionary feminists and in between. And then a lot of the men's movement, whether they're right or left wing, you're seeing a lot of recognition of this. So I do wonder if that's gonna be a new group of users, of people in the future who are seeking out treatment. It's just something to think about because I think that's rapidly changing. The question though is about screening. So when I screen, I work with teen males and they always say no. And that's, I've become suspicious. And also, very honestly, I don't ask the teen females because there are like TikTok videos of these girls that are complaining that they were sexualized by their doctor who asked them these questions. And I was wondering, is there a more anonymous survey or screener that I could give, just like a piece of paper, they could put in a vault or an envelope or something, where we could get that data that way? Yeah, so I think that's why we think about the brief pornography screen. If you go to the, you'll be able to get it as a PDF. You can just have them fill it out. And the thing is, everyone I meet, I just give them a standard battery. So if you screen everyone, it kind of makes it less. I think the thing too is you can also normalize it too. Like a lot of times people, you could say like, you know, no, I know this is common and people use pornography. And then you could kind of segue into that. But I think it would just be screening. I think just have it, they can easily fill it out and probably tell you, yeah. It's also important, how do you ask the question? Yeah, for me, I discovered like long time ago that if I ask, do you watch porn? It's very confrontational. I always ask, how much time do you spend watching porn? How frequently do you watch? And then I ask, did you ever experience any problems because of that? And if there is no, we don't go any deeper. If there is yes, then okay, do you want to talk about it? And very often people say, oh, thanks God, you asked. You know, I've been seeing so many psychologists before and nobody asked me or I mentioned that they didn't know how to talk about it. Yeah. I think this is a very important point because I think one of the slides that Mateusz showed is that the proportion of seven to 12 year olds viewing pornography and these are based not on self-report but from digital device information was about 25%. Yes, both boys and girls. Yeah, so the content of pornography has changed over time so that what was once more considered gonzo pornography is now more mainstream. And the impact that this is having on the development of sexual arousal templates or expectations that youth might have entering into initial relationships can be very significant. So this is a sensitive area to address within clinical settings, but also from a public health perspective. And I think this is an area where different governmental bodies, like what is happening in Canada right now with age verification and how to enforce that with respect to Pornhub and other groups, that this is an important area from a societal perspective. In many countries, it already works, like UK, for example, or South Korea. By default, the adult content is blocked. You need to unblock it, it's possible, but you need to verify your age, as we do here for the investment services, let's say Robinhood or other things like that. Right now in European Union, there is a EU consent program, which is working on the solutions for all adult content for the whole EU. It's doable, but in US, there is no serious ongoing project yet. Yeah, thanks everybody. I'm Darren Hollub from outside of Toronto. Dr. Gola, congratulations on your child. I, too, am a father of three. The youngest is eight years old, and it's a related bit of a selfish type question for all of you. Primary prevention. In my case, when I was a kid, I had very little oversight in terms of my use of computers and gaming and Commodore 64 and later Nintendo, that sort of thing. Arguably, I turned out just fine. But in the case of my eight-year-old, we're quite restrictive in terms of our access. The only time they're allowed to play it without limitation, really, is on an airplane. They wanna take the long route to Australia next time, across the Middle East. He wants to become a video game tester when he gets older. So, any data as far as primary prevention, safe guidelines as far as gaming or screens that you trust for parents among us? So, I was part of a cost initiative, which is a cooperation in science and technology, a European Union initiative that focused on problematic use of the internet. And we developed a publicly accessible how to prevent problematic use of the internet guide that covers a broad range of problematic usage of the internet types, including gaming, but a broader range than we discussed today, including cyberchondria, which is excessive searching for health-related information. But in that booklet, it's an e-booklet that's available on the International College of Obsessive-Compulsive Spectrum Disorders website that Naomi Feinberg oversees, and she was the PI on this initiative. That e-booklet can be downloaded for free and has specific recommendations for parents as to how to prevent problematic usage of the internet. And in other presentations, I have several slides worth of information. But things like removing digital devices from the bedroom as youth are going to sleep is really important, among a whole host of others, but I thought I would mention at least that one. And yes, I was also working on a similar project in Poland and EU, and there were also developed the guidelines on the time on screen for different age groups. And this recommended screen time for the kids up to the age of 12 is below two hours a day. And also, you know, it's important what types of screens they are. Right now, there is increasing body of evidence showing that the small screens are increasing the risk of myopia among kids. And it hasn't been really taken into account in the past, but there is also like a physical risk of developing myopia with use of the screens. Thank you, Dave Kandiff. And grateful to all three of you for such a rich presentation on gambling disorders, gaming disorders, problematic internet use, and problematic sexual issues. You've challenged us to do more screening. And I'm gonna challenge you in return, give us more context. These are important to screen for because they are treatable and they cause a great deal of suffering. They are expensive to screen for because you don't know who you're screening. Remember that while sensitivity and specificity are sort of linked to characteristics of the test, the predictive values of positive and negative tests are much more heavily controlled by the prevalence of the disorder. So the screening that is appropriate, cost-effective, therapeutic, and wise in a psychiatric population or an SUD population may be very different from the screening that is appropriate in primary care. And that kind of context and the nuance behind that context is really valuable as a future direction for research. And I appreciate that. Finally, I would ask us to take a lesson from the US Preventive Services Task Force and remember that all screening when you're thinking about doing it address both the likelihood and certainty of benefit and the likelihood and certainty of harm because no screening can be assumed to be harmless as well as cost-free. Thank you so much. Appreciate that and I look forward to next year. Thank you very much. Thank you and I think those are appropriate points to raise as I think they resonate with some of the questions that were raised earlier, particularly among youth and how to screen. You know I'm gonna talk about screening again, right? No, I really appreciated the presentation. I think for some time a lot of us have known we need to ask something and some of us know not to ask the loaded question like we're here telling them what the right answer is. But in trying to find a way to ask, a lot of patients are used to you just running through substances and then the medical history might reveal like gastric bypass and you're like, oh okay, was that alcohol before or after that? But this is like there's very little that you could gain without kind of directly asking. But we're all short on time and we're not gonna do 19 questions unless maybe we have a suspicion. So not just for hypersexual but for all the stuff, the stuff that maybe the patient's really thinking about hoarding or maybe it's gaming or something else. I have a patient who thinks she reads really too much and isolates and has all the consequences from that. Do you feel like there's one screening question we could ask? There is. That would capture all of it? Yeah. Yeah, the one screening question is, is there any behavior which you feel is, which is not under your control? And people very often are able to identify it if they are losing control over something. Yeah, so for the gambling screen of the BBGS, the first question one is the question that matters. So that's the biggest one. And then same thing for CSB, it's about control. So you're looking at if there's impaired control, difficulty with control. So even the BPS has one question on control or really failure to stop or to control yourself. That's the question also. So again, it's really getting at that thing that matters. Yeah, and so again, it's the amount of time, the sensitivity, specificity, these are all important questions. And what I'm hearing also resonates with someone in GA said, is it to the point where your life is unmanageable? But another question is, do we want to let it get to the point where things are unmanageable? And I think we have to think about how much time we want to devote to screening for these behaviors. And those are individual decisions with respect to the clinics or the clinical settings in which we work. Hi, my name is Ismail. I'm a psychiatry resident from New York. Thank you very much for such an informative presentation on a topic that little known. My question is about the child and adolescent patients who are into internet gaming. Any medication particularly stands out? Also in neuromodulation, is there a reason that we target the LPFC as opposed to other regions? So I didn't quite follow the question. Sure, there was two questions actually. Number one, for a child adolescent with autism spectrum disorder, which tends to have more internet gaming or screening addiction, any medication particularly stands out to utilize? And I mean psychopharmacological medication and neuromodulation, why do we target the LPFC? So there is a, I can try. There is more and more studies showing that there is a higher comorbidity of behavioral addictions, especially now gaming and also compiles like problematic pornography used among individual with autism spectrum disorder or Asperger. And this is probably a fact. We are still, we need more data. It's relatively new research topic, but there are already some evidence for that. The second question, why the LPFC for neurostimulation? Because everyone- Depression, for schizophrenia, for, I wonder what's the secret? Yeah, I can answer that. Why the LPFC? It's because it's a very, it's a very common LPFC, it's because everyone starts studies with the LPFC. It's a very, very wildly connected cortical hub. It's connected with the plenty of subcortical structures like amygdala, ventral stratum and so on. There is a gray matter, white matter tracts which are modulating effectiveness of this connectivity and it's the easiest point to start neuromodulation study. To target other cortical areas, it's more risky. It's probably a matter of time when we learn if it works or not, but everyone starts with the LPFC. It was the best studied cortical hub. And I'll add to that, and thank you, that the dorsolateral prefrontal cortex is not very deep. You can non-invasively stimulate and it fits with dual process models of addiction behaviors with respect to cognitive control over motivated behaviors. And with respect to autism spectrum disorders, yes, there are concerns of high rates of co-occurrence with autism spectrum disorders in a broad range of internet use behaviors, including gaming, but also extending into problematic use of social media and the types of social relationships that people might perceive to be having versus what they are in reality and the troubles that people may get into with using the digital devices for social needs. Thank you very much. I'd be very curious if there is a systematic review or study of resting state fMRI supporting the neural connectivity that the LPFC is actually the reward pathway or? There is plenty of studies showing that actually the white matters connectivity of the DLPFC also is a moderator of the effectiveness of the stimulation. So we know this mechanism more and more and it's actually pretty well documented. Thank you. Dr. Chambers. Dr. Patenza, thank you all and colleagues. Thanks for such interesting talk today. Two questions kind of related, etiology questions and consequences. So is there, given the ACEs are elevated in people who are at risk for addictions in general, doesn't matter what drug it is, we know that's true. Is there a specific etiological link between sexual abuse in childhood or adolescence and that goes specifically to compulsive sexual behavior disorder? So do we have that? The second one is, or is there any signal yet that the availability of pornography for children and adolescents is actually on a public health level changing sexuality so that we're having more of compulsive sexual behavior or is it creating abstinence from non-virtual sex? Those are my two questions. I'll be happy to answer. So the first question. Okay, let's start from the second. Yeah, impairments. So the second one, we know already that from multiple qualitative studies mostly that it is changing sexual behaviors. The availability of the porn is changing the type of sexual behaviors among teenagers and it's changing also canons of the sexual attractiveness. So for example, like shaving pubic hairs. It's a standard these days and it was highly promoted for the pornographic content. And there are studies, qualitative studies from Australia, for example, where teenagers are interviewed how their first sexual encounters looks like. And there is, for example, a trade-off. Okay, if you will give me an oral sex, then I can agree for the anal sex or if you will agree for the anal sex, then I will be kissing you like in the romantic movies and so on. So those things, those behaviors which were less frequent in the past, right now are standards because they are standards very common in the pornographic content. We still lack, we don't have many of the quantitative studies, longitudinal quantitative studies. I think it's an issue of the funding agencies who would like to want to look at that in the systematic way. But there are some changes in the quality of the sexual behaviors. Yeah, and the first question was on. So we have a review, a systematic review that's out. It should be able to search for it, but on sexual abuse and it's associated and between child sexual abuse for both men or for boys and girls and kind of a higher risk for CSB. I think we've done some research on that. I think it's something, the question is, is the pathways, you know? So often you have the avoidance versus the kind of externalization. And I think some of the theories and we have researched, we're looking at this in writing papers, whether the males are more externalization versus girls develop into women who are more internalizing or avoidant of sex. So I think that's the question, but I would say they are positively, it's a robust predictor. So it is. Yeah, it's, yeah, absolutely. So if someone came to me with a male who had a high risk, who had been sexually abused as a child, I would be screening absolutely for CSB, regardless of male or female, yeah. With relationships stronger in males than in females. Yeah, exactly. Hi, my name is Sonia Inside, I'm from Toronto Center for Addiction and Mental Health and my background is in pharmacology and hence the question. So for the pornography, you resist problematic pornography addiction, I believe you showed that there is a high comorbidity with the stimulant like cocaine, correct? No, actually when it comes to pornography, we have high comorbidity with the anxiety disorders and with the depression, yeah, with disorders. And there are very mixed results, depends on the country and study and the sample related to the comorbidity with the substance use disorders. But it's not, I don't know any single study except, you know, like those studies on veterans which Shane was presenting, which would have such a high comorbidities as in gambling disorder as Mark was showing. Okay, so my question is, given that all these pleasure centers are activated during basically when they're using pornography, I'm just wondering if you ever considered doing trials with agonist replacements like drugs that would elevate dopamine. For example, currently there's a lot of research on Vyvanse in cocaine addiction. Yes, I was. I'm just wondering if that's in the pipeline. I like to design clinical trials, so I'm just curious. Unfortunately, it's not in the pipeline yet, but definitely I was very often I was interested in that. Recently, I was also very interested with this, you know, PPG-2 or one, you know, like the substances like, for example, Ozempic. But yeah, it's probably very far in the future if it will happen. Okay, excellent. Thank you so much. We are over time, but we have a last question, so. Yeah, I'll just frame it as a comment. Cannabis and sexual pornography and those kind of behaviors, it seems to be a link. I saw a reference from 2023, but I didn't hear it referenced in the talks. I'd love, my patients tell me they're linked and I see it in the media, but. Very often. This year, so. Yeah, it happens that people who are abusing cannabis, they also have problems either with gaming or pornography watching. Pornography watching goes hand-in-hand with gaming as well, so it happens, yeah. And I'll add just one last point that gaming and pornography use is linked. There are data that when the Fortnite website crashed, the percentage of gamers on Pornhub went up by 10% and searches on Pornhub for Fortnite-related pornography increased by 60%. So there's these complex relationships that we need to understand better. Thank you. Incredible, wasn't it? Thank you. Thank you for educating us in an area that we all can do a lot better with and hope to hear more and more updates in future.

behavioral addiction

clinical considerations

gambling

gaming

sex

digital technologies

compulsive sexual behavior disorder

problematic gambling

gaming disorder

pornography addiction

co-occurrence

mental health conditions

screening tools

treatment options

long-term longitudinal studies

individualized manner