Pornography addiction or something else?

PRESENTING ISSUE

There was a man who was a Sunday School teacher and on his church board who struggled with pornography.  He would drive out of town, buy porn and then take it back to his garage where he would fantasize and masturbate.  Then, in a fit of guilt, he would burn the porn in a "holy ritual" to get rid of porn's effects.  He felt that he had his "addiction" under control because God revealed to him about how to perform this "holy ritual" so that he could still be a "man of God."  

One nite, however, his "holy ritual" did not seem to remove his guilt.  So, in his fervor, he drove around and ended up at a seedy establishment that promised sexual release.  He went into this one room, by himself, where he was to stick a certain part of his anatomy into a hole in the curtain by the wall to be fellated.  He imagined a young, beautiful woman on the other side and felt quite satisfied.  However, as he was getting dressed, he saw a young man slipping out the side.  He was struck with the thought, "what if that was the person and it really wasn't a young, beautiful woman?"  The man felt totally devastated and decided that he needed to get professional help because he has a "pornography addiction."

NOTES His story is consistent with most men's stories.  Most men are introduced to pornography by finding someone's stash, typically a father, uncle or brother.

He found his father's stash in the garage when he was young boy.  It was "just car magazines" but he found himself attracted to the women who posed with these cars and was turned on by their provocative poses. As he developed his interest in his own sexuality, he became more interested in soft-core pornography, then harder pornography. He has kept his sexual interests a secret since finding his father's car magazines. He was only interested in adult, heterosexual pornography. He has only had penile-vaginal intercourse (PVI) with his spouse of 30+ years. He states that their sexual relationship has been non-existent for more than three years. Before his marriage, he had only two sexual relationships. These two prior relationships involved heavy petting and fellatio but did not include PVI or penile-anal intercourse (PAI). He doesn't have any children.

MENTAL STATUS EXAMINATION

Affect: Depressed Appearance: appropriate to age, season, occupation Mood: Dysphoric

Mild psychomotor agitation present

No apparent psychotic phenomena

No noticeable body odor

Denies suicidal/homicidal ideation and intent

Appears to be of average intelligence Judgement and insight appears to be adequate

Speech: Fluid, no idiosyncratic features noted

Sleep: Early morning awakening, insomnia for last 3 years

INITIAL DIAGNOSES

312.89 Other specified impulse control disorder (pornography use causing distress)

780.52 Insomnia disorder, persistent

V61.10 Relationship distress with spouse

R/O: Depressive disorder, anxiety disorder

TREATMENT PLAN

1. Explore fictions related to pornography usage

2. Establish consistent sleep-wake schedule

3. Improve sexual relationship with current partner

4. Understand what happened around 3 years ago

COURSE OF TREATMENT (approx 15 sessions)

• The client came to a better understanding of his pornography use which declined to a less distressing frequency, no longer engaging in "holy rituals"

• His spouse accepted couples counseling (referred to another counselor for couple's counseling)

• His physician placed him on an SSRI to treat his anxiety and depression.

• His insomnia lessened and he no longer had early morning awakening.

• The client came to a better understanding of being a Sunday School teacher and church board member (both which occurred about 3 years prior to seeking treatment) and how that increased his anxiety & depresson of being "addicted to pornography"

• Client's sexual relationship did not improve with spouse
  

DISCHARGE DIAGNOSES

300.4 Persistent Depressive Disorder with anxious distress

V61.10 Relationship distress with spouse