A case report of pornography addiction with dhat syndrome

Abstract

A case of pornography addiction with dhat syndrome was diagnosed applying the existing criteria for substance dependence in International Classification for Diseases-10 and Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision. There is a lack of clear-cut criteria for identifying and defining such behavioural addictions and also lack of medical documents on pornography addiction. An applied strategy in lines with any substance addiction is used, and we found it helped our patient to gradually deaddict and then completely quit watching pornography. This is one of the few cases being reported scientifically, and we hope more work will be carried out in this ever increasing pornography addiction problem.

INTRODUCTION

Addiction can be broadly defined as “compulsive, uncontrollable dependence on a substance, habit, or practice to such a degree that cessation causes severe emotional, mental, or physiological reactions.”[1]

Though the term “addiction” is commonly applied to cases involving the intake of drugs, similar criteria have been used to assess the number of problem behaviors such as eating disorders,[2,3] pathological gambling,[4,5] computer addiction[6] and pathological preoccupation with video games.[7] Today, addiction to pornography is an emerging problem which is associated with significant social, psychological, and occupational impairment.

Currently, the only way to clinically define addictive use to pornography is to compare it with criteria for other established addictions. However, the term addiction does not appear in either Diagnostic and Statistical Manual of Mental Disorders (DSM) Fourth Edition, Text Revision or International Classification for Diseases 10 (ICD-10): Classification of Mental and Behavioral Disorders, so the diagnostic criteria referenced for substance dependence may come the closest in capturing the essence of what has traditionally been labeled as an addiction and would provide a workable definition for identifying and describing various other addictions.[8,9] A broader diagnosis of “sexual addiction” has been described, but there is inconsistency in the criteria provided by different researchers.[10,11]

Recent internet surveys regarding pornography have revealed statistics that speak volumes about the impact, pornography has in the current situation. At present, there are 4.2 million pornographic websites with 68 million daily pornographic search engine requests which are 25% of the total search engine requests every day with the average age of first internet pornography exposure being 11 years.[12]

Though the diagnosis of pornography addiction is debatable, many claim themselves to be addicted to pornography and seek help, majority of them through online forums and very few through psychiatrists. A few websites are available, which are dedicated for providing support to those who are struggling to overcome pornography addiction. Survey done by one of these websites reported that out of 40,000 respondents who joined this website seeking help for pornography addiction and took a self-administered questionnaire on the website, 75% claimed themselves to be addicted to pornography.[13] Another study analyzed 2000 messages sent by 302 members of an Italian self-help internet community for cyber-porn dependents using narrative analysis methodology and suggested that cyber-porn dependence is for many: a real disorder, that can have destructive implications for personal well-being, social adaptation, work, sex life and family relations. Hence, this is one of the most neglected areas requiring further research and effective management module.[14]

CASE REPORT

A 28 year old literate male (unmarried; from urban residency & upper middle-income group; only son out of three children for his parents; brought up in a conservative and rigid family setup) consulted psychiatry out -patient department at JSS Hospital, Mysore with the chief complaint of uncontrollable excessive watching of pornography.

Patient started watching porn at 20 years of age, which was initially only occasional; but progressively increased over a period of 2 to 3 years. Patient lost interest in soft-core pornography early and moved on to watching lesbianism and gang sex porn for the past 6 years, spending on an average 5 or more hours every day in procuring and watching pornographic movies. Progressively, the patient reduced interaction with family members and spent most of the time in his room, downloading and watching pornography and had failed to control the same.

Patient preferred watching and procuring pornography over work, even avoiding interaction with family and friends; his multiple attempts to quit and avoid pornography for even a day would make him restless, irritable, dysphoric; watching the same would relieve the symptoms.

Once started, he would watch pornography for 3-4 hours continuously and occasionally throughout the night. For the last 3 years, the time needed to develop an erection (on watching pornography), had progressively increased, though the interest in watching it remained the same; also, hardness of his erection had decreased. For the last 3 years, he had started assuming that due to seminal loss following masturbation, his potency/manhood had decreased and his semen had become thinner and inferior in quantity, leading to significant distress. He would avoid masturbation as a result of his undue concerns regarding seminal loss, but had continued to watch pornography.

Excessive worrying regarding his manhood/potency, feelings of shame and guilt (due to failure in controlling himself from watching pornography) was present from the past 2 to 3 years. He had developed features suggestive of mild depression (feeling of sadness, excessive guilt, feeling of unworthiness, decreased self-esteem and decreased appetite).

He made his first sexual advances with his girl-friend on a couple of occasions, a month before he came for consultation; however he was not able to perform due to inadequate erection (inspite of having intimacy with his girl friend and adequate foreplay). He constantly kept comparing his girl friend with females in pornographic videos, and he felt that she was not as sensualizing as professionals in pornographic videos. His fears about his future sexual and marital life increased, making him avoid any further sexual intimacy with his girl friend which led him to sought professional help. No features suggestive of homosexuality, other psychiatric disorders, paraphilic disorders were noted. There was history of febrile convulsions between 2 and 4 years of age (no treatment received). Both his father and uncle had alcohol dependence and expired due to complications resulting from hepatocellular carcinoma.

Mental state examination revealed mild depression. The case was given a working diagnosis of “pornography addiction with dhat syndrome with mild depression.”

Patient motivation to quit watching porn was good at the time of consultation and same level of motivation was maintained throughout the therapy period. Initially, patient was given reassurance and sex education for his undue concerns about seminal loss. He was started on desvenlafaxine 50 mg titrated to 100 mg at night. With sex education, his undue concerns regarding semen loss decreased significantly. Later he was started on cognitive behavioral therapy (CBT).

On combined treatment (psychotherapy and Pharmacotherapy), patient showed significant improvement in 4 months. Patient felt much better on follow-up and the compulsion to watch pornography decreased significantly to almost nil; even if he would occasionally watch, he was able to terminate watching pornography after 15-20 min at his will. Patient's self-esteem improved, and he felt hopeful about his marital and sexual life. Patient's medication was gradually tapered; both psychotherapy and pharmacotherapy were stopped after 9 months of treatment in between which he got married too. At the time of documentation of this paper, the patient had got married and was doing well for over a year and was free from any sexual or mental health symptoms, receiving no treatment, but on follow-up visits every 3 months.

DISCUSSION

Criteria to diagnose pornography addiction are not given by ICD or DSM. Symptoms like craving, withdrawal symptoms on cessation of watching pornography, tolerance, narrowing of repertoire, neglecting family and occupation as a result of excessive pornography watching were elicited from the history. Based on these symptoms, the diagnosis of pornography addiction was given. There is undue concern regarding semen loss causing distress to the patient fulfilling the criteria for the dhat syndrome as per ICD-10. Patient fulfilled criteria for depression of mild severity as per ICD. As excessive, uncontrollable pornography watching related problems emerged first and were the chief complaints the patient presented with, pornography addiction was made the primary diagnosis.

Patient might have got habituated to pornographic visual and auditory stimuli and hence took longer time for arousal and erection of penis. But the patient misattributed these symptoms to the semen loss following masturbation and developed undue concern for semen loss that further led to significant distress. As mentioned above habituation to pornographic visual and auditory stimuli and higher expectations from his female partner to be as sensualizing as professionals in pornographic videos might be the reason for the difficulty in arousal and achieving erection with his female partner.

A study on clients with internet addiction treated with CBT revealed that most of them were able to fully manage their symptoms by the twelfth session. CBT was effective at ameliorating the common symptoms of online addiction like: Motivation to quit, online time management, social isolation, sexual dysfunction, and abstinence from problematic online applications.[15,16,17] Our patient was started on CBT and he showed significant improvement.

CONCLUSION

With the emergence of concepts of new lifestyle habits, pornography addiction is one of the major issues to be looked at. Better understanding of pornography addiction is a necessity in order to help the youth who are at a significant risk of suffering from pornography addiction as in the above case.