The DSM is psychiatry's bible. If a disorder isn't in there, insurance companies won't reimburse treatment costs for it, so psychiatrists don't diagnose patients as having it. In the health care world, "Reality is what the DSM says it is."

So, if you fall into compulsive Internet porn use...tough luck. Your condition doesn't exist and you will be treated, if at all, for the unpleasant symptoms of addiction (such as anxiety, ED, depression, concentration problems) on the assumption that these conditions predated, and are unrelated to, your excessive porn use. No one will breathe a word to you about your actual pathology: addiction-related brain changes. It's the equivalent of giving you Vicodin for the pain of your leg fracture instead of setting it—while allowing you to continue limping along on it without a cast.

This move comes just as the DSM's pathological-gambling work group has determined that another highly stimulating, non-substance compulsion, gambling, will be upgraded to the renamed category: Addiction and Related Disorders—so that they can treat such patients for addiction. How, in the name of science, can one compulsion (gambling) be recognized an addiction risk while the other (compulsive sexual behavior) is casually dismissed? 

All addiction is a matter of science

In recent years, the DSM has been taking a lot of heat for generating new mental health pathologies, some of which have resulted in over-diagnosis and over-medication. We understand its desire not to stick out its collective neck just because people chase booty or look at raunchy videos to excess.

However, as the gambling revision indicates, behavioral addictions are now verifiable pathologies "characterized by a loss of rational control, as well as significant and measurable changes in the neurochemistry of the brain." The same physiological mechanisms and anatomical pathways are at work in gambling, video gaming, overeating, drug use and excessive sexual behavior. We now have the tools to measure (across populations) brain changes associated with all addiction. As a neurologist Max Wiznitzer  explained,

We already know what the [brain] imaging profile is for addictive behavior and what the profile is for the reward system, which is the dopamine system. ...[T]his is a nonspecific activation pattern that is not stimulus sensitive. No matter what the addiction, it's going to affect the same areas.

Similarly, Stanford University psychologist Brian Knutson observed:

It stands to reason if you can derange [brain circuits that evolved to reward survival-enhancing behavior] with pharmacology, you can do it with natural rewards too.

In short, rather than demoting or removing "Hypersexual Disorder" from the DSM, the work group should move it to the new Addiction and Related Disorders. Already the DSM acknowledges that pathological gamblers and those suffering from compulsive sexual behaviors often show similar symptoms, such as inability to control use despite negative consequences and escalation to more extreme stimulation. (Compare criteria here and here.)

There are oodles of comforting studies on gamblers' brains using scans and tests, all of which show clearly that excessive gambling can cause physiological changes that are very like the brain changes in substance abusers. In contrast, there are only a couple studies on the brain effects of excessive Internet porn use or sex addiction. However, they do reveal the kinds of ominous changes observed in gamblers' brains.

These lopsided databases don't indicate that today's hyperstimulating porn/chat can't cause addiction—as some sexologists assert. They mean that desperately needed research hasn't been done—and isn't likely to be done very promptly—for reasons we'll get to in a moment.

Gambling researchers have already developed blood tests, cognitive tests and, of course, brain scans that measure key addiction characteristics objectively. While such tests are impractical for individual use, they have helped to establish the diagnostic criteria for addiction-related disorders. It may be that the DSM criteria for diagnosis of hypersexual addiction could already be honed to detect even more accurately the presence (or absence) of addiction-related changes: dopamine dysregulation (numbed pleasure response), sensitization and hypofrontality.

There may, for example, be a marked difference in the brain of someone presenting Tiger Woods-type behavior compared with someone hooked on today's Internet porn and struggling to quit. Consider this young recovering porn user's subjective experience:

After a couple weeks of no PMO (porn/masturbation/orgasm), I tried something completely different - M and O without P - something I've never considered. Two days later, I added the P to the MO on a whim and relapsed. The two experiences were vastly different. Just MO was almost shocking, because I had no uncomfortable buzz afterward, no shift of perception. It turned out to be a sweet, invigorating feeling. In contrast, the full PMO session felt like I was totally on a DRUG. Every picture turned my body into a searing blast of tension, each new one more powerful than the last. I felt almost like a "dope surge" run from my brain through my body. Suddenly I could hear and feel EVERYTHING more intensely. Then it was like a cloud of idiocy swept over me, and everything went numb. That feeling lasted two days at least. Enlightening.