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Purpose of Review Problematic pornography use (PPU) describes a pattern of behavior characterized by excessive time spent using or thinking about pornography and continued use despite negative consequences. To help advance the understanding of transdiagnostic underlying psychological and neurobiological mechanisms in PPU, we aim to review existing evidence on these mechanisms focusing on positive valence systems within the transdiagnostic Research Domain Criteria (RDoC) framework. Recent Findings Reward anticipation processes seem to be increased in individuals with PPU symptoms when they anticipate sexual stimuli compared with other rewards. Studies further suggest that the initial neural and attentional responses to sexual rewards compared with different control stimuli are also increased in individuals with PPU symptoms, as are conditioned responses in sexual reward learning paradigms. Sexual reward valuation studies point towards an increased neural value differentiation with increasing PPU symptoms. Summary The current state of evidence indicates that positive valence systems are altered in persons with PPU. This frame- work of organizing evidence may aid in elucidating PPU development and maintenance as well as planning future studies. Keywords Problematic pornography use · CSBD · RDoC · Reward · Learning · Valuation Introduction While most people experience the use of pornography as Topical Collection on Sex Addiction. relaxing, fun, and sexually exciting [1, 2], some individu- als develop a problematic use pattern. Problematic pornog- * Sanja Klein raphy use (PPU) is mainly characterized by excessive time email@example.com spent using or thinking about pornography, loss of inter- Department of Psychotherapy and Systems Neuroscience, est in other activities, impaired self-control over the use, Justus Liebig University, Otto-Behaghel-Str. 10 H, failed attempts at reducing the use, and continuation or 35394 Giessen, Germany escalation of use despite negative consequences resulting Bender Institute for Neuroimaging (BION), Justus Liebig from the use [3, 4]. It can be estimated that 0.8–8% of por- University, Otto-Behaghel-Str. 10 H, 35394 Giessen, nography users show symptoms of PPU . PPU can be Germany considered as a subtype of compulsive sexual behavior dis- Center of Mind, Brain and Behavior, Universities order (CSBD; ), and research has shown that the major- of Marburg, Giessen, Germany ity of patients seeking treatment for CSBD report PPU as Clinical Psychology and Psychotherapy, University Siegen, their primary problematic sexual behavior . Therefore, 57076 Siegen, Germany current opinions view PPU as a subtype of this construct Department of General Psychology: Cognition [8, 9] and also assume that many patients presenting with and Center for Behavioral Addiction Research, University CSBD will show PPU as their primary problematic sexual of Duisburg-Essen, 47057 Duisburg, Germany 6 behavior. Since the inclusion of CSBD in the International Erwin L. Hahn Institute for Magnetic Resonance Imaging, Classification of Disease (ICD-11; [ 10]) in 2019, CSBD 45141 Essen, Germany 1 3 Current Addiction Reports (2022) 9:114–125 115 is now commonly used as an umbrella diagnosis for PPU In this review, we included all studies that employ reward symptom patterns. in a controlled experimental setting and assess symptoms of Classifying PPU as CSBD may be useful for clinical PPU. We aimed to review clinical studies including patients settings, and the ICD-11 and DSM-5 provide the com- with CSBD (assessed via clinical interview), as well as mon ground necessary to facilitate communication among studies with general population samples, which conducted clinicians. However, the concept of disorders belonging a dimensional PPU measure (for a review of measures see to distinct categories (e.g., mood disorders, anxiety disor- ). Correlations of dimensional PPU measures with ders, addiction) is not enough when the goal is to under- reward processes in these samples may indicate mechanisms stand the underlying psychological and neurobiological in early subclinical problematic behaviors . mechanisms involved in the development of problematic behaviors such as PPU and to eventually develop effec - tive treatments [11, 12]. The Research Domain Criteria Positive Valence Systems in PPU (RDoC; ) present an alternative framework that aims to describe disorders not by category but by underlying In the following, we summarize and discuss PPU study mechanisms at the genetic, molecular, physiological, and results within the respective constructs, sorted based on the behavioral level. These mechanisms are represented in the reported task design and analysis. For an overview of all domains (1) negative valence systems, (2) positive valence included studies, as well as the dimensional indicators of systems, (3) cognitive valence systems, (4) systems for PPU, please see Table 2. social processes, (5) arousal/regulatory systems, and (6) Abbreviation used in the table: het. = predominantly sensorimotor systems (National Institute of Mental Health; or exclusively heterosexual, hom. = predominantly or ). In this review, we aim to summarize the current state exclusively homosexual, SID = sexual incentive delay, of PPU literature from an RDoC perspective to benefit AAT = approach/avoidance t ask, UCS = unconditioned from its transdiagnostic dimensional approach. Specifi - stimulus, CS + = conditioned stimulus associated with cally, we focus on the domain of positive valence systems UCS, CS − = conditioned stimulus not associated with and its subconstructs because most experiments published UCS. CSB = compulsive sexual behavior (criteria by ). in connection with PPU/CSBD lie within this domain. PPU measures: s-IATsex = short internet addiction test, Furthermore, a recent study that examined patients with adapted for sexual content , HBI = Hypersexual Behav- CSBD and healthy control participants in behavioral tasks ior Inventory , SAST-R = Sexual Addiction Screening from the domains of negative valence, positive valence, Test-Revised , SES = sensitivity towards sexual excita- cognitive systems, and sensorimotor systems found group tion , PPUS = Problematic Pornography Use Scale , •• differences in the positive valence domain only [ 15 ]. For BPS = Brief Pornography Screener , PCI = Pornography an overview of positive valence systems according to the Consumption Inventory , Internet Sex Screening Test RDoC, please see Table 1 (definitions adapted from the , PIPUS = Problematic Internet Pornography Use Scale NIMH website; ). . Table 1 The Positive Valence Systems in the Research Domain Criteria framework. Definitions adapted from the National Institute of Mental Health (NIMH) website Construct Definition Reward responsiveness Processes that control an individual’s response to reward in different stages: Reward anticipation Impending or possible reward Initial response to reward Immediate receipt of reward Reward satiation Following repeated receipt of reward Reward learning Processes by which individuals learn information about stimuli, actions and contexts that predict positive outcomes, and by which behavior and expectations are modified including: Probabilistic and reinforcement The ability to learn which actions or stimuli are associated with obtaining a reward learning Reward prediction error Processes associated with the difference between expected and received rewards Habit Repetitive behaviors elicited by triggers that can be a consequence of learning Reward valuation Processes by which the reward value of an expected outcome is computed by a function of its magnitude and: Reward (ambiguity/risk) Valence and predictability Delay The time until its delivery Effort The subjective costs of effort required to obtain it 1 3 116 Current Addiction Reports (2022) 9:114–125 1 3 Table 2 PPU studies in the RDoC Positive Valence Systems domain with information on sample (gender, sexual orientation and clinical characteristics) and paradigm with conditions and stimuli used Construct Subconstruct Study Sample Gender and sexual PPU measure or CSBD Paradigm Conditions Stimuli orientation interview Reward responsiveness Reward anticipation Gola et al. (2017) [29 ] 28 patients, 24 controls Het. men SAST-R, BPS, time spent Informative SID Sexual (low/high magnitude), Photos depicting women in underwear or naked, low amounts using pornography monetary (low/high magnitude) (1–3€) or high amounts of money (10–12€) with varying winning probability (25%, 50%, 75%) •• Draps et al. (2021) [15 ] 74 patients, 66 controls Het. men Diagnostic interview (CSBD Informative SID Sexual (low/high magnitude), Photos depicting women in underwear or naked, low amounts criteria) monetary (low/high magnitude) (1–3€) or high amounts of money (10–12€) with varying winning probability (25%, 50%, 75%) Markert et al. (2021)  74 general population participants Het. men s-IATsex, time spent using Basic SID Explicit-sexual, nonsexual, nothing Videos depicting explicit sexual activities or nonsexual mas- pornography sages, black screen Stark et al. (2022)  157 general population par- Het. men s-IATsex, time spent using Basic SID Explicit-sexual, nonsexual, nothing Videos depicting explicit sexual activities or nonsexual mas- ticipants pornography sages, black screen Initial response to Voon et al. (2014) [37 ] 19 patients, 19 controls Het. men Diagnostic interview (CSBD Passive viewing Explicit-sexual, sexual, non-sexual- Videos depicting explicit sexual activities, dressed women, reward criteria) exciting, money, neutral sporting activities, coins or paper money, landscapes Seok and Sohn (2015)  23 patients, 22 controls Het. men Diagnostic interview (CSBD Passive viewing Explicit-sexual, non-sexual-exciting Photos depicting naked women and sexual activity, sporting criteria), HBI, SAST-R activities Kühn and Gallian (2014)  64 general population participants Men Time spent using por- Passive viewing Explicit-sexual, neutral, nothing Photos depicting explicit sexual activities, physical exercise, nography, Internet Sex nothing Screening Test Laier and Brand (2014)  176 general population par- Het. men s-IATsex, HBI, SES Passive viewing and rating explicit-sexual Photos depicting explicit sexual activities ticipants Laier et al. (2014)  102 general population par- Het. women s-IATsex Passive viewing and rating Explicit-sexual Photos depicting explicit sexual activities ticipants Laier et al. (2015)  71 general population participants Hom. men s-IATsex, HBI, PCI, SES Passive viewing and rating Explicit-sexual Photos depicting explicit sexual activities Mechelmans et al. (2014)  22 patients, 44 controls Het. men Diagnostic interview (CSBD Dot probe Explicit-sexual, sexual, neutral- Photos depicting explicit sexual activities, naked women, criteria) person, neutral-furniture dressed women, pieces of furniture Pekal et al. (2018)  174 general population par- Het. men and women s-IATsex, time spent using Visual probe Explicit-sexual, neutral Photos depicting explicit sexual activities, zoomed-in cut-outs ticipants pornography of the photos without sexual content Snagowski and Brand (2015)  123 general population par- Het. men s-IATsex, HBI, SES AAT Explicit-sexual, neutral-person Photos depicting explicit sexual activities, people in neutral ticipants situations Sklenarik et al. (2019)  72 general population participants Het. men PPUS, BPS AAT Sklenarik et al. (2020)  166 general population par- Het. women PPUS, BPS AAT Explicit-sexual, neutral-objects Photos depicting explicit sexual activities, common household ticipants objects Stark et al. (2017)  100 general population par- 50 men and 50 s-IATsex, time spent using AAT Explicit-sexual, positive, negative, Photos depicting explicit sexual activities, negative scenes, ticipants women pornography neutral positive scenes, people in neutral situations Albery et al. (2017)  55 general population participants 28 het. men and 27 SCS Sexual stroop Sexual, neutral Words with sexual content, neutral content het. women Wang et al. (2021)  57 general population participants Men PIPUS Sexual stroop Sexual, neutral Photos, depicting explicit sexual activities, people in neutral situations Reward valuation Reward (ambigu- Gola et al. (2017) [29 ] 28 patients, 24 controls het. men SAST-R, BPS, time spent fMRI informative SID Sexual (low/high magnitude), Photos depicting women in underwear or naked, low amounts ity/risk) using pornography monetary (low/high magnitude) (1–3€) or high amounts of money (10–12€) with varying winning probability (25%, 50%, 75%) •• Draps et al. (2021) [15 ] 74 patients, 66 controls Het. men Diagnostic interview (CSBD informative SID Sexual (low/high magnitude), Photos depicting women in underwear or naked, low amounts criteria) monetary (low/high magnitude) (1–3€) or high amounts of money (10–12€) with varying winning probability (25%, 50%, 75%) Klein et al. (2020)  72 general population participants Het. men s-IATsex fMRI basic SID Explicit-sexual, nonsexual, nothing Videos depicting explicit sexual activities or nonsexual mas- sages, black screen Brand et al. (2011)  89 general population participants Het. men s-IATsex Passive viewing and rating Explicit-sexual Photos depicting explicit sexual activities Laier et al. (2013)  25 patients, 25 controls Het. men s-IATsex, time spent using Passive viewing and rating Explicit-sexual Photos depicting explicit sexual activities pornography Brand et al. (2016)  19 general population participants Het. men s-IATsex, SES fMRI passive viewing and Explicit-sexual MM, MF, FF Photos depicting explicit sexual activities between two men, a rating man and a woman or two women Delay Negash et al. (2016)  123 general population 32 men and 91 Frequency of pornography Delay discounting Small/large amounts of lottery Text questions, pitting present lottery tickets against future women use tickets (1–6), small/large time lottery tickets to win money windows (15–180 days) Current Addiction Reports (2022) 9:114–125 117 Reward Responsiveness Many studies have examined Reward Responsiveness in both clinical samples and in general population samples in connection with a dimensional PPU measure. We discuss studies concerning the subconstructs reward anticipation (sexual incentive delay (SID) task) and initial response to reward (functional magnetic resonance imaging (fMRI)) and behavioral passive viewing, approach-avoidance task, dot probe task, stroop task). We could not identify any studies examining reward satiation and PPU. Reward Anticipation The SID task is an adaption from a widely established para- digm to examine reward anticipation (monetary incentive delay task, [27, 28]). The task generally contains simple visual cues (symbols, geometric shapes) that signal the possibility of “winning” a reward in the trial but only if the participant reacts quickly enough to a target that is presented after the cue. Different versions of the SID task have been used mostly in fMRI studies [29 , 30, 31] and one behavioral •• study [15 ] to examine reward anticipation in connection with PPU symptoms. The informative SID variant  contains a sexual condi- tion with a potential sexual picture reward, a money condi- tion with a potential monetary reward, and a control condi- tion with no potential reward. During target presentation, the participants press one of two buttons quickly, depending on one of two shapes that is presented as the target. Addi- tionally, the sexual cue and monetary cue contain informa- tion concerning the magnitude (more or less explicit sexual picture, more or less money) and the winning probability (25%, 50%, or 75%) of the potential rewards. Due to this additional information in the cues, outcomes in this task likely reflect both reward anticipation and reward valuation processes. Two studies have used this informative SID task to examine anticipation and valuation processes in partici- pants with PPU; here, we discuss the anticipation effects. An fMRI study [29 ] found that participants with PPU and control participants differed in their striatal responses to sexual cues but not in their responses to sexual pictures themselves. Participants with PPU showed increased ven- tral striatal activity specifically for sexual cues but not for monetary cues compared to the control group. Across the whole sample, relative ventral striatal sensitivity to sexual cues versus monetary cues was significantly related to the increased behavioral motivation to view sexual images (reac- tion time difference between sexual and money trials) and several dimensional indicators of PPU. The shortest reac- tion times overall were found in participants with PPU in •• sexual trials. A behavioral study [15 ] recently employed the informative SID to examine behavioral outcomes. They 1 3 Table 2 (continued) Construct Subconstruct Study Sample Gender and sexual PPU measure or CSBD Paradigm Conditions Stimuli orientation interview Reward learning Probabilistic and Banca et al. (2016)  23 patients, 40 controls Het. men Diagnostic interview (CSBD Classical appetitive condi- CS + , CS + , CS − , CS: visual patterns, UCS: Photos depicting naked women, sexual money reinforcement criteria) tioning UCS, UCS , nothing £1, nothing sexual money learning Klucken et al. (2016) [69 ] 20 patients, 20 controls Het. men Diagnostic interview (CSBD classical appetitive condi- CS + , CS − , UCS , nothing CS: geometric figures, UCS: Photos depicting explicit sexual sexual sexual criteria) tioning activities, nothing Snagowski et al. (2016)  90 general population Het. men s-IATsex Classical appetitive condi- CS + , CS − , distractors, CS and distractors: geometric figures, UCS: photos depicting sexual tioning UCS, UCS explicit sexual activities, people in neutral situations sexual neutral 118 Current Addiction Reports (2022) 9:114–125 found interaction effects in reaction time and subjective rat - the basic SID . Since these results belong to the reward ings of the rewards: Reaction times of patients with CSBD valuation construct, they are further discussed in “Reward were shorter in sexual trials, while those of control partici- Valuation.” From the current state of evidence, motivational pants were shorter in monetary reward trials. Patients also components of reward anticipation for sexual rewards seem rated all sexual rewards and all large rewards higher than to be increased in participants with PPU symptoms, vis- the control group. A simpler version of the SID contains a ible in behavioral data and neural activity — but only under sexual condition with a sexual video reward, a control condi- certain conditions. The results may indicate a potentially tion with a control video reward (pleasant, non-sexual mas- important mechanism involved in PPU, but further research sage video), and another control condition with no potential is needed to disentangle how incentive sensitization may reward . This basic SID also uses only one target with a change in different situations and with increasing disorder simple one-button reaction. In the basic SID, no relationship severity and how it interacts with reward valuation. was found between the neural activity during sexual cues or sexual videos contrasted with the control condition with any Initial Response to Reward dimensional indicators of PPU in a generally healthy sample . Interestingly, the authors assessing the healthy sample Considering the construct of initial response to reward, we under acute stress found that a dimensional PPU indicator included fMRI [37 , 38, 39] and behavioral [40–42] studies moderated the effect of an acute cortisol stress response on using passive viewing paradigms, i.e., studies in which par- neural activity related to the sexual cues and sexual videos ticipants were asked only to view the sexual stimuli, some- . Participants who reported more time spent on pornog- times with subsequent ratings, but without other behavioral raphy use showed less neural reactivity to sexual cues and tasks during the experiment. We further included behavioral videos in the orbitofrontal cortex, the more stressed they studies using an approach-avoidance task (AAT; [43–46]), a were, measured by the individual cortisol response. Orbito- dot probe task [47, 48], and a stroop task [49, 50]. frontal cortex activity reflects the abstract value of rewarding Voon et al. [37 ] found that patients with CSBD demon- stimuli [33, 34], so to these participants, the anticipated and strate greater activity in the ventral striatum, dorsal ante- experienced stimuli may have been devalued in the stressful rior cingulate cortex (dACC), and amygdala when viewing situation. explicit sexual videos compared with videos of exciting In summary, the results from the informative SID studies sporting activities. Using pictures instead of videos, another point to behavioral and neural reward anticipation processes study found increased activity in dACC, thalamus, dorsal that are sensitized towards sexual over monetary rewards in striatum (caudate nucleus), and prefrontal cortex in patients participants with PPU as the popular incentive sensitization in an explicit sexual-exciting sports contrast . The theory of addiction proposes . This theory postulates authors further found the thalamic and prefrontal activity in that repeated use of a substance sensitizes reward circuitry to this contrast to be positively related with dimensional indica- cues associated with substance use, and attributes increased tors of PPU. Contrasting work found a negative correlation incentive effects to these cues. Transferred onto PPU, the between time spent using pornography and dorsal striatal reward circuitry would attribute increased incentive salience (putamen) reactivity to similar sexual pictures in a general to cues that signal pornography use. In contrast, the basic population sample . A series of behavioral studies exam- SID did not show similar results with dimensional indicators ined the change in self-reported sexual arousal induced by of PPU — effects on reward anticipation only emerged when viewing explicit sexual pictures in different samples. They participants were under acute stress. One reason for these found similarly high correlations between a dimensional discrepancies between studies could be that incentive sen- indicator of PPU and task-related change in sexual arousal sitization in PPU-related anticipatory processes are not yet in heterosexual men , homosexual men , and hetero- visible in subclinical participants. Another likely reason are sexual women . the differences between the two tasks that may have engaged The fMRI findings indicate that direct neural responses slightly different underlying processes, such as the control to sexual rewards are altered in patients with CSBD, likely condition (money reward versus massage video reward). The reflecting increased motivational salience of sexual rewards different results indicate that anticipation processes may be [51–56]. The frequent use of pornography for instant sex- sensitized towards sexual compared to monetary reward but ual gratification, relaxation, and stress-relief can be seen not compared to other immediate non-sexual rewards. A as repeated learning sessions through which the associa- very interesting difference is the reward value information tion between visual sexual stimuli and a positive outcome contained in the informative SID cues because effects of this is strengthened in patients with PPU. These increased information in connection with PPU were also found [29 ]. neural responses may only be visible in clinical samples Notably, effects of PPU on neural processing of subjective because for these individuals, we can assume a more exces- reward value in the subclinical sample were also found in sive individual learning history, and thus increasingly firm 1 3 Current Addiction Reports (2022) 9:114–125 119 associations between sexual stimuli and positive outcomes is not completely understood. The dot probe task measures coming into the experiment. Furthermore, sexual videos attentional bias by presenting two pictures, on either side rather than pictures are probably more similar to the stimuli of a screen; in this case, one sexual and one control picture. that pornography users are familiar with  which may After the picture offset, a dot is presented in the location of be why they seem to recruit more of the established condi- one of the former pictures, and the participants are instructed tioned reward regions . The self-reported larger increase to react quickly to this dot. Quicker reaction time to the dot in sexual arousal in individuals with more PPU symptoms when it occurs in the previous location of a sexual picture could reflect a similar mechanism. However, self-report as and slower reaction time when it occurs in the previous loca- a measure of sexual arousal is probably influenced more tion of the control picture is interpreted as greater attentional strongly by cultural and societal norms regarding pornogra- bias towards sexual pictures. In such a paradigm (but with phy use and individual attitudes towards sexuality [58–60] arrows instead of dots), Pekal et al.  found a dimensional so it might be less reliable. Altogether, initial response to indicator of PPU to be associated with the attentional bias reward regarding direct physiological responses to sexual towards sexual stimuli. A similar study  also found a rewards is strongly involved in PPU. Most studies suggested greater attentional bias towards explicit sexual pictures in increased responses to disorder-related rewards as opposed patients with CSBD compared to the control group. The to only one study indicating blunted reward responses . attentional bias for sexual words measured via reaction time The other studies in this domain measure behavioral in a stroop task  was also found to be positively related approach/avoidance biases (AAT; ) and attentional to a dimensional indicator of PPU. Finally, in a more recent biases towards sexual rewards (dot probe, stroop; ). In stroop task using sexual images with colored frames, Wang this version of the AAT with sexual stimuli, participants et al. found that a group with high scores on a PPU measure are instructed to push stimuli away from or pull them displayed a greater attentional bias towards sexual images towards themselves by means of a joystick attached to the via reaction time interference effects and event-related computer . Relative differences in times are interpreted potentials compared to a group with low PPU scores . as approach (i.e., shorter pull than push reaction times) or The discussed evidence points towards increased avoidance biases (i.e., shorter push than pull reaction times), approach and attentional biases for sexual stimuli associated respectively, for a given picture category. Sklenarik et al. with PPU symptoms. This would fit with the fMRI data, sup -  have reported an overall approach bias for sexual com- porting the notion of increased sexual stimuli salience due to pared to neutral images and found a positive relationship more prior learning experiences, but the results are difficult between a dimensional indicator of PPU and the approach to integrate because of significant differences in designs. For bias scores in a sample of heterosexual men from the general example, AAT studies with the most straightforward results population. With the same task in a sample of heterosexual used pictures of neutral objects as the only control condition women from the general population, the authors reported a for sexual pictures [44, 45]. The sexual approach bias from slightly smaller approach bias for sexual compared to neutral such designs could represent a genuine bias towards sexual images , but also a positive relationship between the content. Concurrently, it could also represent a mere bias sexual approach bias and another indicator of PPU. Another towards pictures of humans. Hence, more rigorous study study including men and women from the general popula- designs with different stimulus categories are essential to tion, using an AAT with negative and positive emotional disentangle varying accounts. Furthermore, while the AAT pictures alongside sexual and neutral pictures, found no and the dot probe task are useful proxies for attention and stronger overall approach bias for sexual pictures compared approach processes, it may be beneficial to use other, more to the other pictures . However, the approach bias for direct measures to further assess behavioral initial response sexual pictures here was also positively correlated with an to reward in connection with PPU. One possibility would be indicator of PPU. Another AAT study  did not find any to capture overt attention via eye tracking (e.g., dwell time, linear relationship between indicators of PPU and approach scan path) during free exploration of complex pictures with or avoidance biases towards sexual compared with neutral explicit sexual content. stimuli but a u-shaped association with both approach and avoidance tendencies being associated with symptom sever- Reward Valuation ity. Some findings point to the fact that physiological condi - tions (i.e., alcohol intoxication) and/or psychological con- Most studies that exist in this domain engage both reward ditions (i.e., arousal) may foster biased responding towards responsiveness and reward valuation in the tasks they sexual stimuli and that such biases are associated with sexual employ. Many classic reward valuation paradigms such risk intentions . Overall, results concerning the approach as forced-choice preference, willingness-to-pay, risky bias towards sexual stimuli as an indicator of compulsive decision-making, or probability discounting (for a review sexual behavior are still mixed, and the potential mechanism of valuation studies see ) have not yet been employed 1 3 120 Current Addiction Reports (2022) 9:114–125 in connection with PPU. One delay discounting study  in future studies, especially when looking at PPU develop- found stronger devaluation of monetary rewards due to ment versus maintenance. delay in participants who spent more time on pornogra- phy use in a general population sample but did not include Reward Learning sexual rewards. No other studies concerned with delay or effort and PPU were identified. In the following, we discuss The studies that examined reward learning as a factor in reward (ambiguity/risk) studies that used sexual rewards PPU have used classical appetitive conditioning paradigms and examined reward valuation processes in task design or [69 , 70, 71] and thus belong to the probabilistic and rein- •• • analysis [15 , 18, 29 , 36, 67]. forcement learning subconstruct. Classical appetitive con- ditioning describes the process by which an initially neutral Reward (Ambiguity/Risk) stimulus (conditioned stimulus; CS +) is repeatedly paired with a reward (unconditioned stimulus; UCS). In differential The results of these studies point towards altered valuation conditioning paradigms, another neutral stimulus (CS −) is of sexual rewards in participants experiencing PPU symp- never paired with the UCS. After few pairings, participants toms. As we already touched upon before, the cues in the show increased responses to the CS + compared to the CS − , informative SID  contain information on magnitude and such as increased valence and arousal ratings, elevated probability of the following sexual and monetary rewards, skin conductance responses (SCRs), and activities of the i.e., reward value information. Gola et al. [29 ] found that brain reward circuitry [72–75]. Studies explicitly examin- the generally stronger ventral striatal activity in response to ing reward prediction error or habit in PPU could not be sexual cues in patients with PPU was modulated by the mag- identified. nitude presented in the cue. In the basic SID, the individual ratings of sexual videos and neural activity in ventral as well Probabilistic and Reinforcement Learning as dorsal (caudate nucleus) striatum were found to be cor- related more strongly in participants who reported more PPU Banca et al.  examined the reactions of patients with symptoms . In another fMRI study, higher ventral stri- CSBD and control participants in conditioning paradigms atal responses to preferred sexual pictures compared to non- inside the MRI scanner and outside. Outside of the scan- preferred sexual pictures were found in a general population ner, participants took part in two differential behavioral sample . This ventral striatal activity relative to prefer- conditioning tasks, one with a CS + that announced an money ence was again correlated with self-reported PPU symptoms. UCS (£1) and one with a CS + that announced an money sexual Finally, behavioral studies found PPU symptoms to be corre- UCS (photo of naked woman). Both tasks also contained sexual lated with sexual arousal ratings [18, 68] and viewing times a CS − that announced nothing/the absence of the UCS. Con- of preferred pictures  in general population samples. A ditioned reactions to the CS + were probed afterwards in a self-selected PPU group also rated generally non-preferred forced-choice preference task. Patients with CSBD were more sexual pictures (homosexual male/male pictures, heterosex- likely to select the CS + versus the CS − compared to sexual ual sample) higher than the control group . control participants. However, patients also showed greater The increased association between subjective value of preference towards the CS + compared with CS − than money sexual rewards and (ventral) striatal activity indicates that the control group. Thus, patients showed greater condi- this region differentiates more strongly between differently tioned preference overall, independent of UCS type. In the preferred stimuli, the more PPU symptoms a participant MRI, the conditioning task contained all three conditions experiences. The increased differentiation of incentive value (sexual, money, nothing). Two CS per condition (CS + , sexual signals in the striatum might reflect a heightened sensitivity CS + , CS −) were paired with UCS, UCS , or money sexual money to sexual reward value information, perhaps mediated by nothing, similar to the behavioral task. There were no group a greater need for seeking, identifying, and responding to differences in CS-related activity. However, activity associ - preferred sexual stimuli during PPU development. A value ated with viewing the UCS in the dACC fell steeper over sexual differentiation effect like this was however not found in the experiment than activity for UCS in the CSBD group money behavioral data . The clinical (patients with CSBD) sam- compared to control group. In the control group, there was no ple in the same study even seemed to show a generalization change in activity towards either UCS over the experiment. of preference across unexpected stimuli . Altogether, Another classical conditioning study, [69 ] examined the neu- reward valuation of sexual stimuli seems to be a crucial ral activity during a task with no money condition and a more factor in PPU and should be researched further, with more explicit UCS , also in a clinical sample. Thus, the stimuli sexual studies directly targeting valuation processes (e.g., active were CS + , CS − , UCS , and nothing/absence of the sexual sexual choice paradigms; ). Value differentiation as well as UCS. The authors found increased amygdala activity for the value generalization effects should be given much attention CS + versus the CS − in the CSBD group compared to the sexual 1 3 Current Addiction Reports (2022) 9:114–125 121 control group. Additionally, they found decreased functional men in the studies we identified. Only in the subconstruct connectivity during the contrast CS + > CS − between the initial response to reward, we found studies also includ- sexual ventral striatum and prefrontal cortex in the CSBD compared ing heterosexual women [41, 45, 46, 48, 49] and one study to control group. Finally, in a behavioral appetitive condition- including homosexual men . Therefore, findings related ing study , a CS + was always paired with a UCS to reward anticipation, reward valuation, and reward learn- sexual sexual and a CS − with a UCS . The authors found that the more ing while promising are for now still limited to one demo- neutral PPU symptoms a participant reported, the higher they rated graphic subgroup. Notably, sexual orientation is assessed the CS + on sexual arousal after conditioning as com- dimensionally (via the Kinsey scale; ) and reported sexual pared to before. transparently in most studies, which is not the case for gen- The findings suggest enhanced conditioned responses in der identity. The current lack of measurement and reporting patients with CSBD, visible through behavioral preference, of sample gender information  makes it dic ffi ult to know ratings, and amygdala activity. Furthermore, the decreased for example whether trans and/or nonbinary individuals were coupling between prefrontal cortex and ventral striatum indi- included and whether the authors assessed sex assigned at cates decreased inhibitory control, which may facilitate trig- birth (suggested by the use of “male”/ “female” terminol- ger-responses [76, 77]. The UCS -specific decrease in ogy) or gender identity (“men”/ “women” terminology). sexual dACC activity in patients with CSBD  may be explained More transparent and rigorous reporting of gender and by a decrease in predicted action-outcome value over the inclusion of more than one gender and sexual orientation experiment . Therefore, from the studies we discussed group in studies on PPU is especially important when we here, appetitive conditioning seems to be an important fac- consider that these person characteristics have been shown tor in PPU. However, it is not yet clear if these effects are to interact with other behavioral addictions as well as sub- specific for learning situations that involve sexual UCS, due stance abuse [86–88]. An issue complicating the integration to patients’ extensive experience with these stimuli before of findings across experiments is the diversity of stimuli. the experiment. It might also be the case that patients show a Experimental control stimuli ranged from generally reward- generally increased reward sensitivity as proposed by impul- ing pleasant or arousing stimuli over neutral person images sivity theories of addiction [78–80] and supported by the to objects such as furniture or household items. Stimuli in behavioral data . Another reward learning factor consid- the sexual condition ranged from pictures of dressed women ered important in most other addictions is appetitive extinc- over images of naked people to explicit images or videos tion [81, 82]. Extinction describes the process whereby the of sexual intercourse. Comparisons between these varying association between CS + and UCS becomes weakened, types of sexual and control stimuli may reflect a variance and the individual learns that the CS + no longer signals of underlying mechanisms. A similar point can be made for the UCS. One important factor in PPU, which some authors the range of different dimensional indicators of PPU that conceptualize as a disorder due to addictive behaviors and were used. Many different PPU questionnaires are in use not as subtype of CSBD, is that patients keep using pornog- currently  but especially the assessment of only time raphy, even when the once positive outcomes can no longer spent using pornography as a proxy for problematic use pat- be expected; hence, extinction deficits can be assumed to terns is debated . play an important role in explaining the maintenance of this behavior [3, 83]. Banca et al.  included an extinction task after conditioning where all CS were shown again with- Conclusion out the UCS. However, no group effects were found during extinction, so the role of this process in PPU remains incon- The current state of literature indicates that the RDoC- clusive at this point. Altogether, reward learning, classical positive valence systems are important factors in PPU. conditioning in particular seems to be an important mecha- For reward anticipation, the evidence indicates incentive nism in PPU, but there is still much left to shed light on such sensitization towards stimuli announcing sexual rewards in as the roles of temporal difference learning, instrumental patients with PPU, but it is still unclear which situational conditioning, extinction, and generalization. factors contribute to this process. Similarly, most studies found increased initial response to reward, as shown in neural responses and attentional/approach biases to sexual Limitations rewards associated with PPU symptoms. This could be due to patients’ prior learning history with these rewards. Some factors that limit the conclusions we can draw regard- Reward valuation studies reported an increased differen - ing positive valence systems for PPU are sample character- tiation of sexual reward values associated with PPU. This istics, the diversity of sexual and control stimuli, and the might reflect heightened sensitivity to sexual reward value diversity of PPU measures. There is a focus on heterosexual information which could be a precursor or consequence of 1 3 122 Current Addiction Reports (2022) 9:114–125 5. Castro-Calvo J, Cervigón-Carrasco V, Ballester-Arnal R, PPU. Finally, reward learning studies have shown increased Giménez-García C. Cognitive processes related to problematic conditioned responses to stimuli associated with sexual pornography use (PPU): a systematic review of experimental reward in classical conditioning paradigms. It is still unclear studies. 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Current Addiction Reports – Springer Journals
Published: Sep 1, 2022
Keywords: Problematic pornography use; CSBD; RDoC; Reward; Learning; Valuation
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