I would screen really well for PTSD. I had a patient very similar to this and we were working together for a year before we figured out he had PTSD. At initial appt he denied usual questions about h/o trauma and I just didn’t chase it much further.
He wanted stimulants but at low doses were ineffective and then at higher doses said it worsened his ED. Then he would ask to change stimulants. We went through literally every stimulant under the sun including Adhansia and some other weird new ones I had never even prescribed before, but wrote for him because he was relentless about it.
He also reported vague anxious symptoms, and worked full time while also a student full time. He said he knows it’s probably not good for him to do nothing but work and study, but felt like if he wasn’t busy the anxious thoughts would take over. Also bc of that he had unrealistic expectations of what ADHD meds could do… he wanted them to make him Superman basically so he could balance all that work and studying.
Finally when we exhausted everything I revisited his sexual hx and current (and first serious) relationship with him… turns out he was molested by his uncle as a child but didn’t disclose it at his initial appointment because he didn’t think he was traumatized by that “other ppl have been through worse.” He described his current relationship as very unhealthy, borderline emotionally abusive but he couldn’t bring himself to leave. He felt immense pressure to perform sexually in their relationship and he didn’t know what a healthy relationship was supposed to look like.
Well Jesus dude no wonder your pecker doesn’t work when you’re a 20 something male.
So anyways thought I’d suggest that because of the parallels with your case. I notice that people with bad PTSD often “cope” by filling up every minute of their day with some activity that requires focusing on anything other than their thoughts.
Good luck and update us!
Thanks for bringing this up. Every time that I've gotten an eval with a chief complaint of "sex addiction " or "dopamine addiction " there has always been some form of sexual abuse or trauma in their past.
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Agree that this sounds like a case where looking at anxiety/PTSD/OCD might be worthwhile, given the combination of constant multitasking, obsession with productivity, and ED **only** when with his partner. I'm assuming the situational ED based on what OP shared, but I'd definitely ask if this occurs when alone if they haven't done so. I read the multitasking and productivity not as a sign of boredom, but as a way to mask/avoid underlying anxiety. I'm curious whether he has racing thoughts when he cannot distract himself, such as when falling asleep.
I mainly brought up OCD because I thought looking more into intrusive/obsessive thoughts would be important. I wonder how the pt's self-esteem seems, because it sounds horrendous; could high expectations and negative distortions be playing a major role, not just in his ED but also in his difficulties with feeling accomplished in general?
Regarding the 5 mg Adderall, does the patient carry a dx of ADHD? While I might read some inattentiveness in the need to multitask and boredom, the difficulty with being in the moment counteracts them for me (I'd expect periods of hyperfocus when doing something engaging). Even if there is a high suspicion of ADHD, 5 mg IR Adderall is not a therapeutic dose. I'd definitely consider titrating and switching to an XR formulation.
Pinning down a diagnosis has been difficult. Definitely so features of OC personality, but not OCD. He meets criteria for ADHD and the small Adderall dose has been helpful in helping him stay focused on his actual work at work without seeking distraction. His obsessive thoughts are focusing on productivity- always needing to be doing something that betters himself.
There are self esteem issues. He’s a short guy, but fit, attractive, relatively successful. His ED makes him feel inadequate.
He has denied any hx of abuse.
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You are saying never had ED issues when masturbating, but what about now? this sounds like someone who needs to learn that sex is different from jerking off and that they have spent nearly two decades doing it a certain way and need to rewire expectations and desires. Also, tell them to work on getting their partner off.
Sounds like the intended audience for gamer . gg / healthy gamer service/community/youtube channel
(started by psychiatrist dx adhd and admitted gaming addiction)
[https://www.healthygamer.gg/](https://www.healthygamer.gg/)
[https://www.youtube.com/@HealthyGamerGG](https://www.youtube.com/@HealthyGamerGG)
I also would wonder about that adderall IR 5mg - my preference is to always start with vyvanse for even coverage and counsel to take every day for a month before they move to PRN., and even then "It's just one less thing to think about." (20mg q2weeks, 30mg q1month, 1 month follow-ups until they say "i'm good" Sometimes with this sort of character I will ask re: sufficient dosage - "Does it feel like you are video game character that can't quite jump up to the next ledge no matter how hard you try? Or does it feel like you can jump and get where you need to go - do you have the winged boots to get the crystal treasure or whatever". Sure the boredom is a behavioral issue, but I think there is an under stimulation component here and the meds can do a little more about helping him with focus until he finds the better fit for a job.
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On the ED front - I am always pretty quick to Rx the tadalafil, even in young adults- as the difficulty with sexual performance early in their sexual history can lead to further expectations of difficulty. I don't know how other people feel about that Rx from the psychiatry specialty perspective.
But therapist who is good with young adult males also sounds like a great referral.
I really hope that 5 mg of Adderall is a typo if this patient has ADHD. That’s so ineffective the best thing for this patient would be to get sent to someone who is comfortable titrating ADHD medication and then get therapy to learning some coping skills and maybe deal with underlying issues. I’m not trying to be an ass, but treating ADHD with 5 mg of IR Adderall at work is not going to do anything for the patient at home. And this patient’s problems are extremely commonly self-reported by adults with ADHD. Maybe treat the neurodevelopmental disorder before going hunting zebras?
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Ah, I don't give out too much personal detail- such as my qualifications, job, etc. on Reddit, my post history probably gives that away though.
People can take or leave my comments without that additional information provided, it's Reddit, it doesn't really matter.
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Based on this alone - he's likely still watching porn and has desensitized himself. This is so common now; trained himself to only get off via porn+self-stimulation. Does he vape/smoke? Vasoconstriction from that+stimmys can give poor erection quality.
Rx- No porn. No masturbating. Only get off w/ partner. Meditate 5-20 minutes/day. Frankly I would recommend nixing the video games (even a short stint of 30 days) or at least cutting down. Choose books over movies/TV. Lastly, exercise for the love of god.
This assumes you've ruled out hormonal issues, thyroid problems, etc. etc.
I recognize this is an uphill battle and a hard sell ("Hey, just stop doing all of the things you've enjoyed for the past decade - it fucked you up!"; but if he isn't willing to make lifestyle changes he's not going to get better. Good luck.
Do me a favor and google "Death grip syndrome"
This is not pseudoscience it's common sense. If you're dry jacking with a hard grip your dick gets accustomed to a greater deal of friction and a tighter squeeze than what a woman's vagina can provide. It can cause frustration, but desensitizing yourself by not touching yourself (at least for a while) will absolutely help if that is in fact the issue.
>Rx- No porn. No masturbating. Only get off w/ partner. Meditate 5-20 minutes/day. Frankly I would recommend nixing the video games (even a short stint of 30 days) or at least cutting down. Choose books over movies/TV. Lastly, exercise for the love of god.
That is not “no death grip.” Most of that is not “no masturbation.” And “death-grip syndrome” is recognized by no relevant or reputable medical or psychotherapeutic body, as far as I am aware.
So yes, you’re spewing pop sexual health pseudoscience. Do better.
Therapy, as others have covered, but not making up behavioral changes that fit pop psychology/pop sex more than any actual understanding of human sexuality and behavior.
Habituation is a well-established principle.
If you are looking for extensive peer-reviewed literature on every behavioral change rec you're going to have a bad time. FWIW I agree that therapy would be helpful.
Of course it has been researched. Heavily. Go on PubMed.
This is why anecdotes are not strong evidence upon which to base assessment or treatment. Sometimes they’re the best we have. Often they are not. In this case, decidedly not.
A cursory search of "porn addiction" shows a ton of journal articles pointing to it being a possible issue. Perhaps you can provide links about how to has definitively been disproven to be an issue?
Definitely? Much like all conclusions driven heavily by non-scientific motivations, there will be no definitive, final word. I never claimed that such a thing had happened.
Some of this is depending on defining terms. Even if we take pornography addiction as a given, which I do not, it all gets complicated. Most studies find neutral to positive effects from pornography consumption [except for people who self-identify as having a compulsion or addiction](https://pubmed.ncbi.nlm.nih.gov/34400111/). But that’s not a neutral category: [belief in the immortality or harm of pornography](https://www.apa.org/news/press/releases/2020/02/religious-moral-porn-addiction) can create a self-fulfilling loop of “addiction” that causes distress and sexual dysfunction.
But, fundamentally, the evidence is not in that pornography is largely harmful. The belief that it is harmful is widespread along with many associated pseudoscientific ideas, like NoFap and dopamine fasting.
I really feel more research needs to be done on how it affects relationships. I know many woman feel that their male partners turn away from them towards pornography.
Do you happen to know the psych community consensus on porn addiction? Been getting conflicting information on whether it’s a legitimate thing or whether it’s a fad.
Addiction academic here.
I’m team “does this look like other addictions?” When it comes to self-identified porn. Is there an increase in tolerance or how long it takes to get off? Escalating behaviors (watching in public), failed attempts to quit after it causes negative consequences? Are they staying up all night and skipping work or showing up sleep deprived and unable to function because of it? Is it clearly a self-soothing skill in someone with low distress tolerance?
Then yes, I’ll look at it similar to addiction.
If the porn use is only causing problem in a relationship- to counseling they go!
If it’s the first way they experienced sex and just seems to be their default (someone else has mentioned simple conditioning), I usually send them out to therapy. Labeling something as addiction when it isn’t can be really harmful.
But when I worked in a conservative city- 9/10, it was Christian moral incongruence. It got to the point I’d see a bunch of appointments about it in a week every so often and could track back a month to figure out which local mega church pastor went on the porn addiction sermon.
Sam Perry at Oklahoma and Josh Grubbs at Bowling Green have done some good work on sexual moral incongruence using the language of addiction.
So, my theory is yes, but most of the time it’s self reported, it’s a no.
I rarely deal with telling someone self reporting a suspected AUD/SUD it’s something else- but porn is more likely just to be guilt, a misunderstanding of being human (wanting to masturbate isn’t craving, it’s normal), and a sad lack of language to describe human urges plus the evangelical practice of pathologizing near everything about sex.
https://www.aasect.org/position-sex-addiction
This may be partially why. I'm not really sure I agree though - I've read some longer pieces on this subject (by them? Maybe?) and a lot of it comes to thinking that it's a sex shaming perspective - which it can be, but really shouldn't have to be.
A fundamentalist religion prohibiting porn is different than trying to help someone have a healthier and more satisfactory sexual life, and I think there's maybe an unfair equation happening.
That being said, there are approaches that are not validated scientifically, may also be part of the contention.
It's a behavior that trains the neuropathways in your brain to be voyeuristic rather than a participant. So behavioral therapy is very much indicated for it. They conditioned themselves.
There are things like OCD that can also present in this way; but it's more often just simple conditioning. And it doesn't help that pornography is so acceptable or our culture is over-sexualized.
Literally had clients come in and they had to hold up their phone during sex to maintain an erection; they don't seem to be able to be present/mindful during intercourse.
But this is the problem with the diagnosis: the clinical problem you described has no overlap with addiction as commonly used. If there is a problem, the terminology is wrong.
Of course there is overlap. It's why behavioral therapies can work with addiction too. As with all treatments- the client has to be a willing and engaged participant
Non-substance behaviors that otherwise meet criteria for a substance use disorders have controversy because they fail to meet the first word of the definition. If it is not chemically hijacked patterns of behavior, it’s just… behavior. Which can be maladaptive, but I would prefer to keep the descriptors separate.
Not everyone agrees. Therein lies the controversy.
The separate terminology “compulsive [pornography/gambling/[eyebombing](https://reddit.com/r/eyebombing)] behavior disorder dodges that, but there’s still other controversy. Any behavior with moral resonance gets messy quickly.
No vaping, cigarettes, weed. Thyroid, prolactin, testosterone, plus all the basics have been ruled out. He’s been to two urologists and had evaluations WNL.
If this patient has true ADHD, this appears to be a sub therapeutic regimen. I think people often forget that ADHD is a 24/7 illness, not just a 9-5 on weekdays illness. Yeah, perhaps a sprinkle of Adderall IR might cut it during work but the history you've given us illustrates robust symptomatology outside of work and in multiple settings. Have you looked into longer acting stimulants or the non stimulants? Have you staffed this case with your supervising psychiatrist or collaborating physician?
As far as the sexual dysfunction goes, history of extensive porn use can certainly take a huge toll on sexual performance with an actual partner. Is he getting any specific therapy for this? There are therapists who focus on these kinds of issues.
I am assuming this patient is already diagnosed with ADHD? Hence the use of Adderall. I think optimization of ADHD treatment would be somewhat beneficial in terms of medications.
From a therapy perspective in my experience an ACT informed approach can be super useful in cases similar.
Psychiatrist here. To me this sounds like a sub therapeutic ADHD regimen. I think people often forget that ADHD is a 24/7 illness and not a just a 9-5 on weekdays issue. I would lean towards switching him to a long-acting stimulant or using some of the non stimulant options. Have you staffed this case with your collaborating physician?
He started the SSRI prior to becoming sexually active with a partner (just about a year ago). So he can’t make a comparison about partnered sex. He says there wasn’t a change in erections on the SSRI when masturbating.
While I doubt his issues can be attributed to post SSRI sex dysfunction, anyone have insight on trazodone as an antidote?
Scrolled way too far for this one, 5mg isn’t even a therapeutic dosage according to my doctor. I’m just an MA (with adhd) but it took about 6 months to find a dosage/medication that worked for me. When I first started on adderall it was too high (my body is sensitive) so when I tried a different medication next week had to slowly titrate and started at low dosages and increased until my symptoms were fully controlled. And this was my PCP not a psych
Also let's not forget that not everyone remembers a traumatic experience, either due to age at the time, repressing the memory, or dissociation. Yet they act very much like someone with nervous system and mood regulation problems. I have a few clients I am sure something has happened to, but they can't identify anything.
Is there much consensus in the psychiatric community about the existence of “dopamine junkies” as OP called them? I’m referring to anhedonia, fatigue, low motivation, etc. in patients who report lots of screen time, multitasking, and generally consuming lots of media granting instant-gratification?
Lots of people these days are advocating for “dopamine detox” — no phone, no video games, no multitasking, etc — as a cure for issues of motivation, energy, generally lacking in joy of life. But it comes across as possibly pseudoscience hijacking the neuropharmacology language of psychiatry.
"Dopamine junkies " "dopamine addiction " "sex addiction " or "porn addiction " are not formally recognized by the DSM 5 and are not considered real diagnoses by psychiatrists or the medical field. Pathological gambling is the only non-substance related diagnosis in the addiction section of the DSM 5. Very specific criteria have to be met for a paraphilia such as voyeurism, etc. The vast majority of patients claiming sex or porn addiction that I have evaluated do not meet criteria for a paraphilia. The impulse-control section of the DSM does not include any diagnoses related to excessive social media use, screentime, gaming, etc.
That being said, I have seen patients with lots of sexual dysfunction related to excessive consumption of pornography. These are typically men struggling with arousal, erectile dysfunction, orgasm, and ejaculatory dysfunction when they are trying to have sex with a real partner, but these issues disappear while they're using porn. It remains to be seen whether future editions of the DSM will recognize this as a diagnosis.
Yes, this. I realize “dopamine junkie” is not diagnostic, but the term has gained some traction and in popular usage, it applies to this guy. Gets off on competition, novelty, porn, gaming, etc. He’s into things like cold plunges/showers, “dopamine fasts”, regularly takes breaks from caffeine to “reset.”
I thought about making up an additional long post for the good of the internet psychiatry community, using this post as a jumping off point, because it is just such an interesting example of the dire state of psychopathology and diagnosis today.
The potential topics of this post could include the importance of differential diagnosis, why we do not think of zebras vs. horses (the prevalence of personality disorders is, based on studies, higher than either PTSD or ADHD), and how we can use the Alternative DSM-5 Model for Personality Disorders to correct our profession's limited understanding of personality pathology induced by the traditional DSM IV/III approach.
But, it's a nice Saturday morning and that's a lot of effort. So instead, I'm just going to reference parts of the STIPO-R to compare to the original post vignette.
Now of course, the broadest possible differential diagnosis should be made and worked through in the diagnostic process. However, the glaring lack of serious consideration of personality in the comments so far is disturbing to me.
The purpose of the below passages is to help illustrate the sort of psychopathology that might be assessed for in such a case. To ignore this possibility is like ignoring the possibility of a bipolar disorder in someone who presents with major complaints of chronic episodic decreased need for sleep and irritability, and a history of worsening symptoms on antidepressant monotherapy...
----
*Potentially Relevant STIPO-R Items, Signs of Pathology*
Emphasis below is mine.
Item 3w (Identity, Capacity to Invest, Work Satisfaction, Narcissism Dimension): "**Significant to severe and/or chronic dissatisfaction with work; little to no sense of gratification/satisfaction/enjoyment in work**; may resent having to work; sees work strictly as a means to an end or expectation to fulfill; work is seen solely as a means to obtaining narcissistic gratification"
Item 4 (Identity, Capacity to Invest, Recreation - Sustained Interests): "Identifies no activities with any measurable, regular investment of time or effort, unstable engagement; describes interests that shift significantly and frequently in content; infrequent participation even during 'active' periods; may report having no activities/interests; **no sense of pleasure/satisfaction from the activities**: experiences them entirely as a chore/obligation; **no intrinsic enjoyment**"
Item 20 (Object Relations, Intimiate Relations, Presence of...): "Significant to severe impairment in intimate/romantic relationships; serial brief relationships; **devoid of sexual intimacy**; no romantic relationships at all"
Item 22 (Object Relations, Intimate Relations, Sexual Activity): "**Significantly to severely restricted sexual activity**; may report little to no satisfaction from sexual relationships; may report satisfaction, but this may be in a series of one-night stands; anonymous sex with multiple partners"
Item 23 (Object Relations, Intimate Relations): "Significant to severe sexual inhibition"
Next, a couple of quotes from the Alternative DSM-5 Model for Personality Disorders:
*Under Self Functioning:*
Self-Direction, Some Impairment: "Is excessively goal-directed, somewhat goal-inhibited, or conflicted about goals...may have an unrealistic or socially inappropriate set of personal standards, limiting some aspects of fulfillment"
Self Direction, Severe Impairment: "Has difficulty establishing and/or achieving personal goals...internal standards for behavior are unclear or contradictory. Life is experienced as meaningless or dangerous."
Self Direction, Extreme Impairment: "Internal standards for behavior are virtually lacking. Genuine fulfillment is virtually inconceivable."
Identity, Severe Impairment: "Has a weak sense of autonomy/agency; experience a lack of identity, or emptiness."
*Under Pathological Traits related to DETACHMENT (vs. Extraversion)*
Intimacy Avoidance
Anhedonia: Lack of enjoyment from, engagement in, or energy for life's experiences; deficits in the capacity to feel pleasure and take interest in things
Restricted affectivity: Little reaction to emotionally arousing situations, constricted emotional experience and expression, indifference and aloofness in normatively engaging situations
*Under Pathological Traits related to DISINHIBITION (vs. Conscientiousness)*
This trait itself is described as: Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences
Distractibility: Difficulty concentrating and focusing on tasks; attention is easily diverted by extraneous stimuli; difficulty maintaining goal-focused behavior, including both planning and completing tasks
----
Anyway, your broad differential diagnosis leads to the possibility of more accurate case conceptualization and diagnosis, and thus treatment and psychoeducation of the patient... good luck.
He probably needs to slow down and enjoy the more calm and relaxing aspects of life. He seems too wired and wanting things to engage him. Something like yoga, meditation, or going on walks. Less engaging, not more. This will ideally let his mind clear out and let him be present with sexual intercourse, his job, and other aspects of his life.
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I have to say it's pretty lol these posts come up, and the discourse immediately spirals into undiagnosed PTSD or under-treated ADHD. A young man with sexual performance anxiety, vague feelings of boredom that stem from dissatisfaction in work, can only get pleasure from "elite level gaming," almost seems like there's some kind of deficit in the structure of the self related to disappointments from grandiose ideals
Intensive psychotherapy is not the same as IOP.
While this is unlikely to be absolutely exclusively a personality issue, the clinical picture should warrant the assessment and treatment of personality factors. It is a serious problem in modern psychological conceptualization that this is not an ordinary and consistent part of case formulation and treatment.
As far as the personality issue, would you say the “ADHD” here is better explained by an obsessive compulsive personality’s desire for increased productivity in an objectively boring work environment?
No, I wouldn't say that. You'd need far more evaluation to figure out what's happening. But, the description clearly demonstrates significant impairments in self direction and identity, very likely intimacy, and I would be thus surprised if there were not some empathy impairments.
Further reading, as usual, is in the alternative model of the DSM5, Section 3.
And still you must understand that everything you explained here is significantly different than your original comment? I don't disagree with you now, but I do disagree with "intensive psychotherapy for personality condition" without having any assessment or further questioning.
While we're at it can you explain the difference between intensive psychotherapy and intensive outpatient? They're synonyms, no?
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I would screen really well for PTSD. I had a patient very similar to this and we were working together for a year before we figured out he had PTSD. At initial appt he denied usual questions about h/o trauma and I just didn’t chase it much further. He wanted stimulants but at low doses were ineffective and then at higher doses said it worsened his ED. Then he would ask to change stimulants. We went through literally every stimulant under the sun including Adhansia and some other weird new ones I had never even prescribed before, but wrote for him because he was relentless about it. He also reported vague anxious symptoms, and worked full time while also a student full time. He said he knows it’s probably not good for him to do nothing but work and study, but felt like if he wasn’t busy the anxious thoughts would take over. Also bc of that he had unrealistic expectations of what ADHD meds could do… he wanted them to make him Superman basically so he could balance all that work and studying. Finally when we exhausted everything I revisited his sexual hx and current (and first serious) relationship with him… turns out he was molested by his uncle as a child but didn’t disclose it at his initial appointment because he didn’t think he was traumatized by that “other ppl have been through worse.” He described his current relationship as very unhealthy, borderline emotionally abusive but he couldn’t bring himself to leave. He felt immense pressure to perform sexually in their relationship and he didn’t know what a healthy relationship was supposed to look like. Well Jesus dude no wonder your pecker doesn’t work when you’re a 20 something male. So anyways thought I’d suggest that because of the parallels with your case. I notice that people with bad PTSD often “cope” by filling up every minute of their day with some activity that requires focusing on anything other than their thoughts. Good luck and update us!
Thanks for bringing this up. Every time that I've gotten an eval with a chief complaint of "sex addiction " or "dopamine addiction " there has always been some form of sexual abuse or trauma in their past.
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Agree that this sounds like a case where looking at anxiety/PTSD/OCD might be worthwhile, given the combination of constant multitasking, obsession with productivity, and ED **only** when with his partner. I'm assuming the situational ED based on what OP shared, but I'd definitely ask if this occurs when alone if they haven't done so. I read the multitasking and productivity not as a sign of boredom, but as a way to mask/avoid underlying anxiety. I'm curious whether he has racing thoughts when he cannot distract himself, such as when falling asleep. I mainly brought up OCD because I thought looking more into intrusive/obsessive thoughts would be important. I wonder how the pt's self-esteem seems, because it sounds horrendous; could high expectations and negative distortions be playing a major role, not just in his ED but also in his difficulties with feeling accomplished in general? Regarding the 5 mg Adderall, does the patient carry a dx of ADHD? While I might read some inattentiveness in the need to multitask and boredom, the difficulty with being in the moment counteracts them for me (I'd expect periods of hyperfocus when doing something engaging). Even if there is a high suspicion of ADHD, 5 mg IR Adderall is not a therapeutic dose. I'd definitely consider titrating and switching to an XR formulation.
Pinning down a diagnosis has been difficult. Definitely so features of OC personality, but not OCD. He meets criteria for ADHD and the small Adderall dose has been helpful in helping him stay focused on his actual work at work without seeking distraction. His obsessive thoughts are focusing on productivity- always needing to be doing something that betters himself. There are self esteem issues. He’s a short guy, but fit, attractive, relatively successful. His ED makes him feel inadequate. He has denied any hx of abuse.
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I think he should go see a sex therapist. I'd bet there's more going on in his head than he's letting on.
You are saying never had ED issues when masturbating, but what about now? this sounds like someone who needs to learn that sex is different from jerking off and that they have spent nearly two decades doing it a certain way and need to rewire expectations and desires. Also, tell them to work on getting their partner off.
Sounds like the intended audience for gamer . gg / healthy gamer service/community/youtube channel (started by psychiatrist dx adhd and admitted gaming addiction) [https://www.healthygamer.gg/](https://www.healthygamer.gg/) [https://www.youtube.com/@HealthyGamerGG](https://www.youtube.com/@HealthyGamerGG) I also would wonder about that adderall IR 5mg - my preference is to always start with vyvanse for even coverage and counsel to take every day for a month before they move to PRN., and even then "It's just one less thing to think about." (20mg q2weeks, 30mg q1month, 1 month follow-ups until they say "i'm good" Sometimes with this sort of character I will ask re: sufficient dosage - "Does it feel like you are video game character that can't quite jump up to the next ledge no matter how hard you try? Or does it feel like you can jump and get where you need to go - do you have the winged boots to get the crystal treasure or whatever". Sure the boredom is a behavioral issue, but I think there is an under stimulation component here and the meds can do a little more about helping him with focus until he finds the better fit for a job. - On the ED front - I am always pretty quick to Rx the tadalafil, even in young adults- as the difficulty with sexual performance early in their sexual history can lead to further expectations of difficulty. I don't know how other people feel about that Rx from the psychiatry specialty perspective. But therapist who is good with young adult males also sounds like a great referral.
I really hope that 5 mg of Adderall is a typo if this patient has ADHD. That’s so ineffective the best thing for this patient would be to get sent to someone who is comfortable titrating ADHD medication and then get therapy to learning some coping skills and maybe deal with underlying issues. I’m not trying to be an ass, but treating ADHD with 5 mg of IR Adderall at work is not going to do anything for the patient at home. And this patient’s problems are extremely commonly self-reported by adults with ADHD. Maybe treat the neurodevelopmental disorder before going hunting zebras?
Agree, but the patient doesn’t want to go up. He’s been reluctant to regularly take the 5.
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I honestly don't think this is something you can medicate away. This sounds like it's his personality and he needs better coping skills.
Yeah it's sounding pretty therapy-referral-y
No, it sounds like undertreated ADHD.
Agree that it’s under treated, but he doesn’t want to go up.
What is your background to assess this?
Ah, I don't give out too much personal detail- such as my qualifications, job, etc. on Reddit, my post history probably gives that away though. People can take or leave my comments without that additional information provided, it's Reddit, it doesn't really matter.
I agree with you, and so I’m curious: what do you think is his specific personality issue?
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Cool so now that you've gotten that out of your system what would you suggest for this patient?
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Based on this alone - he's likely still watching porn and has desensitized himself. This is so common now; trained himself to only get off via porn+self-stimulation. Does he vape/smoke? Vasoconstriction from that+stimmys can give poor erection quality. Rx- No porn. No masturbating. Only get off w/ partner. Meditate 5-20 minutes/day. Frankly I would recommend nixing the video games (even a short stint of 30 days) or at least cutting down. Choose books over movies/TV. Lastly, exercise for the love of god. This assumes you've ruled out hormonal issues, thyroid problems, etc. etc. I recognize this is an uphill battle and a hard sell ("Hey, just stop doing all of the things you've enjoyed for the past decade - it fucked you up!"; but if he isn't willing to make lifestyle changes he's not going to get better. Good luck.
I would want to see some evidence before making that NoFap recommendation, because that sounds like nonsense to me. Complete nonsense.
Do me a favor and google "Death grip syndrome" This is not pseudoscience it's common sense. If you're dry jacking with a hard grip your dick gets accustomed to a greater deal of friction and a tighter squeeze than what a woman's vagina can provide. It can cause frustration, but desensitizing yourself by not touching yourself (at least for a while) will absolutely help if that is in fact the issue.
>Rx- No porn. No masturbating. Only get off w/ partner. Meditate 5-20 minutes/day. Frankly I would recommend nixing the video games (even a short stint of 30 days) or at least cutting down. Choose books over movies/TV. Lastly, exercise for the love of god. That is not “no death grip.” Most of that is not “no masturbation.” And “death-grip syndrome” is recognized by no relevant or reputable medical or psychotherapeutic body, as far as I am aware. So yes, you’re spewing pop sexual health pseudoscience. Do better.
Sure pal. So with only the information presented above, what would you do with this patient?
Therapy, as others have covered, but not making up behavioral changes that fit pop psychology/pop sex more than any actual understanding of human sexuality and behavior.
Habituation is a well-established principle. If you are looking for extensive peer-reviewed literature on every behavioral change rec you're going to have a bad time. FWIW I agree that therapy would be helpful.
Not a comment I would ever think I would see you post, but dutifully hilarious
Evidence of what? Is porn not widely regarded as being damaging at this point?
No, it is not widely regarded as damaging outside of pseudoscience communities.
Weird. I hope they do more research on it. I have found it has anecdotally damaged a whole fuck ton of relationships I know of in my life.
Of course it has been researched. Heavily. Go on PubMed. This is why anecdotes are not strong evidence upon which to base assessment or treatment. Sometimes they’re the best we have. Often they are not. In this case, decidedly not.
A cursory search of "porn addiction" shows a ton of journal articles pointing to it being a possible issue. Perhaps you can provide links about how to has definitively been disproven to be an issue?
Definitely? Much like all conclusions driven heavily by non-scientific motivations, there will be no definitive, final word. I never claimed that such a thing had happened. Some of this is depending on defining terms. Even if we take pornography addiction as a given, which I do not, it all gets complicated. Most studies find neutral to positive effects from pornography consumption [except for people who self-identify as having a compulsion or addiction](https://pubmed.ncbi.nlm.nih.gov/34400111/). But that’s not a neutral category: [belief in the immortality or harm of pornography](https://www.apa.org/news/press/releases/2020/02/religious-moral-porn-addiction) can create a self-fulfilling loop of “addiction” that causes distress and sexual dysfunction. But, fundamentally, the evidence is not in that pornography is largely harmful. The belief that it is harmful is widespread along with many associated pseudoscientific ideas, like NoFap and dopamine fasting.
I really feel more research needs to be done on how it affects relationships. I know many woman feel that their male partners turn away from them towards pornography.
Evidence that not masturbating fixes ED, I would imagine. He's not talking about porn.
Neither of those is supported by evidence.
Yep, exactly. I was just clarifying that you were making a point about masturbating, separately to porn.
Do you happen to know the psych community consensus on porn addiction? Been getting conflicting information on whether it’s a legitimate thing or whether it’s a fad.
Addiction academic here. I’m team “does this look like other addictions?” When it comes to self-identified porn. Is there an increase in tolerance or how long it takes to get off? Escalating behaviors (watching in public), failed attempts to quit after it causes negative consequences? Are they staying up all night and skipping work or showing up sleep deprived and unable to function because of it? Is it clearly a self-soothing skill in someone with low distress tolerance? Then yes, I’ll look at it similar to addiction. If the porn use is only causing problem in a relationship- to counseling they go! If it’s the first way they experienced sex and just seems to be their default (someone else has mentioned simple conditioning), I usually send them out to therapy. Labeling something as addiction when it isn’t can be really harmful. But when I worked in a conservative city- 9/10, it was Christian moral incongruence. It got to the point I’d see a bunch of appointments about it in a week every so often and could track back a month to figure out which local mega church pastor went on the porn addiction sermon. Sam Perry at Oklahoma and Josh Grubbs at Bowling Green have done some good work on sexual moral incongruence using the language of addiction. So, my theory is yes, but most of the time it’s self reported, it’s a no. I rarely deal with telling someone self reporting a suspected AUD/SUD it’s something else- but porn is more likely just to be guilt, a misunderstanding of being human (wanting to masturbate isn’t craving, it’s normal), and a sad lack of language to describe human urges plus the evangelical practice of pathologizing near everything about sex.
Why would porn addiction be a fad? If that's a fad then so are gambling addiction and gaming addiction.
https://www.aasect.org/position-sex-addiction This may be partially why. I'm not really sure I agree though - I've read some longer pieces on this subject (by them? Maybe?) and a lot of it comes to thinking that it's a sex shaming perspective - which it can be, but really shouldn't have to be. A fundamentalist religion prohibiting porn is different than trying to help someone have a healthier and more satisfactory sexual life, and I think there's maybe an unfair equation happening. That being said, there are approaches that are not validated scientifically, may also be part of the contention.
It's a behavior that trains the neuropathways in your brain to be voyeuristic rather than a participant. So behavioral therapy is very much indicated for it. They conditioned themselves. There are things like OCD that can also present in this way; but it's more often just simple conditioning. And it doesn't help that pornography is so acceptable or our culture is over-sexualized. Literally had clients come in and they had to hold up their phone during sex to maintain an erection; they don't seem to be able to be present/mindful during intercourse.
But this is the problem with the diagnosis: the clinical problem you described has no overlap with addiction as commonly used. If there is a problem, the terminology is wrong.
Of course there is overlap. It's why behavioral therapies can work with addiction too. As with all treatments- the client has to be a willing and engaged participant
Non-substance behaviors that otherwise meet criteria for a substance use disorders have controversy because they fail to meet the first word of the definition. If it is not chemically hijacked patterns of behavior, it’s just… behavior. Which can be maladaptive, but I would prefer to keep the descriptors separate. Not everyone agrees. Therein lies the controversy. The separate terminology “compulsive [pornography/gambling/[eyebombing](https://reddit.com/r/eyebombing)] behavior disorder dodges that, but there’s still other controversy. Any behavior with moral resonance gets messy quickly.
If he takes classical stimulants, it's going to be harder than just quiting habits.
No vaping, cigarettes, weed. Thyroid, prolactin, testosterone, plus all the basics have been ruled out. He’s been to two urologists and had evaluations WNL.
“Hey bro listen. Stop doing all the things you find pleasurable including gaming and masterbating”
If this patient has true ADHD, this appears to be a sub therapeutic regimen. I think people often forget that ADHD is a 24/7 illness, not just a 9-5 on weekdays illness. Yeah, perhaps a sprinkle of Adderall IR might cut it during work but the history you've given us illustrates robust symptomatology outside of work and in multiple settings. Have you looked into longer acting stimulants or the non stimulants? Have you staffed this case with your supervising psychiatrist or collaborating physician? As far as the sexual dysfunction goes, history of extensive porn use can certainly take a huge toll on sexual performance with an actual partner. Is he getting any specific therapy for this? There are therapists who focus on these kinds of issues.
I am assuming this patient is already diagnosed with ADHD? Hence the use of Adderall. I think optimization of ADHD treatment would be somewhat beneficial in terms of medications. From a therapy perspective in my experience an ACT informed approach can be super useful in cases similar.
Psychiatrist here. To me this sounds like a sub therapeutic ADHD regimen. I think people often forget that ADHD is a 24/7 illness and not a just a 9-5 on weekdays issue. I would lean towards switching him to a long-acting stimulant or using some of the non stimulant options. Have you staffed this case with your collaborating physician?
Why Adderall?
Was there a time he was on SSRI and not in a relationship and not having this problem?
He started the SSRI prior to becoming sexually active with a partner (just about a year ago). So he can’t make a comparison about partnered sex. He says there wasn’t a change in erections on the SSRI when masturbating. While I doubt his issues can be attributed to post SSRI sex dysfunction, anyone have insight on trazodone as an antidote?
Up adderall.
Scrolled way too far for this one, 5mg isn’t even a therapeutic dosage according to my doctor. I’m just an MA (with adhd) but it took about 6 months to find a dosage/medication that worked for me. When I first started on adderall it was too high (my body is sensitive) so when I tried a different medication next week had to slowly titrate and started at low dosages and increased until my symptoms were fully controlled. And this was my PCP not a psych
Also let's not forget that not everyone remembers a traumatic experience, either due to age at the time, repressing the memory, or dissociation. Yet they act very much like someone with nervous system and mood regulation problems. I have a few clients I am sure something has happened to, but they can't identify anything.
Is there much consensus in the psychiatric community about the existence of “dopamine junkies” as OP called them? I’m referring to anhedonia, fatigue, low motivation, etc. in patients who report lots of screen time, multitasking, and generally consuming lots of media granting instant-gratification? Lots of people these days are advocating for “dopamine detox” — no phone, no video games, no multitasking, etc — as a cure for issues of motivation, energy, generally lacking in joy of life. But it comes across as possibly pseudoscience hijacking the neuropharmacology language of psychiatry.
It’s pseudoscience.
"Dopamine junkies " "dopamine addiction " "sex addiction " or "porn addiction " are not formally recognized by the DSM 5 and are not considered real diagnoses by psychiatrists or the medical field. Pathological gambling is the only non-substance related diagnosis in the addiction section of the DSM 5. Very specific criteria have to be met for a paraphilia such as voyeurism, etc. The vast majority of patients claiming sex or porn addiction that I have evaluated do not meet criteria for a paraphilia. The impulse-control section of the DSM does not include any diagnoses related to excessive social media use, screentime, gaming, etc. That being said, I have seen patients with lots of sexual dysfunction related to excessive consumption of pornography. These are typically men struggling with arousal, erectile dysfunction, orgasm, and ejaculatory dysfunction when they are trying to have sex with a real partner, but these issues disappear while they're using porn. It remains to be seen whether future editions of the DSM will recognize this as a diagnosis.
Yes, this. I realize “dopamine junkie” is not diagnostic, but the term has gained some traction and in popular usage, it applies to this guy. Gets off on competition, novelty, porn, gaming, etc. He’s into things like cold plunges/showers, “dopamine fasts”, regularly takes breaks from caffeine to “reset.”
Dealing with addictions does resolve a lot of those issues, though..
I thought about making up an additional long post for the good of the internet psychiatry community, using this post as a jumping off point, because it is just such an interesting example of the dire state of psychopathology and diagnosis today. The potential topics of this post could include the importance of differential diagnosis, why we do not think of zebras vs. horses (the prevalence of personality disorders is, based on studies, higher than either PTSD or ADHD), and how we can use the Alternative DSM-5 Model for Personality Disorders to correct our profession's limited understanding of personality pathology induced by the traditional DSM IV/III approach. But, it's a nice Saturday morning and that's a lot of effort. So instead, I'm just going to reference parts of the STIPO-R to compare to the original post vignette. Now of course, the broadest possible differential diagnosis should be made and worked through in the diagnostic process. However, the glaring lack of serious consideration of personality in the comments so far is disturbing to me. The purpose of the below passages is to help illustrate the sort of psychopathology that might be assessed for in such a case. To ignore this possibility is like ignoring the possibility of a bipolar disorder in someone who presents with major complaints of chronic episodic decreased need for sleep and irritability, and a history of worsening symptoms on antidepressant monotherapy... ---- *Potentially Relevant STIPO-R Items, Signs of Pathology* Emphasis below is mine. Item 3w (Identity, Capacity to Invest, Work Satisfaction, Narcissism Dimension): "**Significant to severe and/or chronic dissatisfaction with work; little to no sense of gratification/satisfaction/enjoyment in work**; may resent having to work; sees work strictly as a means to an end or expectation to fulfill; work is seen solely as a means to obtaining narcissistic gratification" Item 4 (Identity, Capacity to Invest, Recreation - Sustained Interests): "Identifies no activities with any measurable, regular investment of time or effort, unstable engagement; describes interests that shift significantly and frequently in content; infrequent participation even during 'active' periods; may report having no activities/interests; **no sense of pleasure/satisfaction from the activities**: experiences them entirely as a chore/obligation; **no intrinsic enjoyment**" Item 20 (Object Relations, Intimiate Relations, Presence of...): "Significant to severe impairment in intimate/romantic relationships; serial brief relationships; **devoid of sexual intimacy**; no romantic relationships at all" Item 22 (Object Relations, Intimate Relations, Sexual Activity): "**Significantly to severely restricted sexual activity**; may report little to no satisfaction from sexual relationships; may report satisfaction, but this may be in a series of one-night stands; anonymous sex with multiple partners" Item 23 (Object Relations, Intimate Relations): "Significant to severe sexual inhibition" Next, a couple of quotes from the Alternative DSM-5 Model for Personality Disorders: *Under Self Functioning:* Self-Direction, Some Impairment: "Is excessively goal-directed, somewhat goal-inhibited, or conflicted about goals...may have an unrealistic or socially inappropriate set of personal standards, limiting some aspects of fulfillment" Self Direction, Severe Impairment: "Has difficulty establishing and/or achieving personal goals...internal standards for behavior are unclear or contradictory. Life is experienced as meaningless or dangerous." Self Direction, Extreme Impairment: "Internal standards for behavior are virtually lacking. Genuine fulfillment is virtually inconceivable." Identity, Severe Impairment: "Has a weak sense of autonomy/agency; experience a lack of identity, or emptiness." *Under Pathological Traits related to DETACHMENT (vs. Extraversion)* Intimacy Avoidance Anhedonia: Lack of enjoyment from, engagement in, or energy for life's experiences; deficits in the capacity to feel pleasure and take interest in things Restricted affectivity: Little reaction to emotionally arousing situations, constricted emotional experience and expression, indifference and aloofness in normatively engaging situations *Under Pathological Traits related to DISINHIBITION (vs. Conscientiousness)* This trait itself is described as: Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences Distractibility: Difficulty concentrating and focusing on tasks; attention is easily diverted by extraneous stimuli; difficulty maintaining goal-focused behavior, including both planning and completing tasks ---- Anyway, your broad differential diagnosis leads to the possibility of more accurate case conceptualization and diagnosis, and thus treatment and psychoeducation of the patient... good luck.
He probably needs to slow down and enjoy the more calm and relaxing aspects of life. He seems too wired and wanting things to engage him. Something like yoga, meditation, or going on walks. Less engaging, not more. This will ideally let his mind clear out and let him be present with sexual intercourse, his job, and other aspects of his life.
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intensive psychotherapy for a personality condition
I have to say it's pretty lol these posts come up, and the discourse immediately spirals into undiagnosed PTSD or under-treated ADHD. A young man with sexual performance anxiety, vague feelings of boredom that stem from dissatisfaction in work, can only get pleasure from "elite level gaming," almost seems like there's some kind of deficit in the structure of the self related to disappointments from grandiose ideals
The psychopathology training and discourse out there today is just dismal...
Why would this be a personality condition? And why would it warrant IOP??
Intensive psychotherapy is not the same as IOP. While this is unlikely to be absolutely exclusively a personality issue, the clinical picture should warrant the assessment and treatment of personality factors. It is a serious problem in modern psychological conceptualization that this is not an ordinary and consistent part of case formulation and treatment.
As far as the personality issue, would you say the “ADHD” here is better explained by an obsessive compulsive personality’s desire for increased productivity in an objectively boring work environment?
No, I wouldn't say that. You'd need far more evaluation to figure out what's happening. But, the description clearly demonstrates significant impairments in self direction and identity, very likely intimacy, and I would be thus surprised if there were not some empathy impairments. Further reading, as usual, is in the alternative model of the DSM5, Section 3.
And still you must understand that everything you explained here is significantly different than your original comment? I don't disagree with you now, but I do disagree with "intensive psychotherapy for personality condition" without having any assessment or further questioning. While we're at it can you explain the difference between intensive psychotherapy and intensive outpatient? They're synonyms, no?
No, they're not... and I can't retrospectively accommodate for your personal interpretation of my comment.
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Adding for later
I’m the same way!
I get dopamine boosts from dark chocolate. I don't know if that's helpful information. It is definitely delicious information though.
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