Category Archives: Culture Bound Syndromes
While researching a previous blog on Stendhal Syndrome, I came across various references to a number of “city syndromes”. According to an interesting book chapter by Nadia Halim, city syndromes are “acute, (usually) short-lived disorders that have in common a similar set of symptoms and pattern of onset and recovery”. Each of the city syndromes that have been identified in the psychological literature is associated with a specific tourist destination (e.g., Jerusalem, Paris, Florence) and identified by medical practitioners (usually psychiatrists) when sufferers access mental health services. In essence, the condition is a type of ‘culture shock’ where an individual becomes psychologically disorientated when they experience new environments that feel alien to them.
One such city syndromes is ‘Paris Syndrome’, a psychological condition that appears to affect Japanese tourists only, suggesting that it is some kind of culture bound syndrome. According to an article in the BBC News, Paris Syndrome was first identified in 1986 by Professor Hiroaki Ota (a Japanese psychiatrist who was working in France at the time). The condition is said to cause mental breakdown when visiting the city. The incidence of the disorder is very small as reports estimate that only 10-20 people a year suffer out of millions of tourists. However, the only ‘cure’ is for the affected individuals to return back to Japan.
As far as I am aware, there are only a couple of academic papers that have been published on Paris Syndrome. The first one was a case study published in a 1998 issue of the Journal of the Nissei Hospital by Dr. Katada Tamami. This was a report of a male manic-depressive who shortly after visiting Paris presented with symptoms of insomnia, fluctuation of mood, aggression, irritation and increase in sex drive. Tamami noted that being separated from his family, and living alone in Paris, the man had an identity crisis as in Paris he was no longer a father or professor. His fantasy and idealization of Paris played a large part in his abnormal behaviour.
The second paper was by a group of French psychiatrists in a 2004 issue in the French psychiatry journal Nervure. The authors reported that between 1988 and 2003, a total of 63 Japanese patients had been hospitalized because of the condition (with a slight bias towards females in their 30s). Although the number of affected patients was relatively low, the Japanese Embassy arranged for a Japanese psychiatrist to work in the authors’ hospital (i.e., St. Anne’s Hospital). In fact, the Japanese Embassy has a 24-hour telephone hotline for Japanese tourists suffering from severe culture shock. The paper claimed that for affected individuals, the city of Paris held a “quasi-magical” attraction and that it was characteristically “symbolic of all the aspects of European culture that are admired in Japan”. A Wikipedia article on Paris Syndrome claims that: “the susceptibility of Japanese people may be linked to the popularity of Paris in Japanese culture”. The same article also noted that:
“Mario Renoux, the president of the Franco-Japanese Medical Association, states in Liberation’s article ‘Des Japonais entre mal du pays et mal de Paris” (December 13, 2004) that Japanese magazines are primarily responsible for creating this syndrome. Renoux indicates that Japanese media, magazines in particular, often depict Paris as a place where most people on the street look like fashion models and most women dress in high-fashion brands”.
The symptoms of Paris Syndrome are typically transient and include anxiety attacks, violent and aggressive outbursts, feelings of persecution, acute psychotic delusions (of paranoia, megalomania, erotomania and/or mysticism), dissociative and/or disoriented feelings, depersonalization, derealization, psychomotor abnormalities (e.g., dizziness, sweating, tachycardia), and – in some cases – thoughts of suicide. Interviews with the affected individuals revealed that the Japanese arrive in the city with highly romanticized expectations and that many had spent years dreaming of coming to Paris before doing it in actuality.
The authors of the paper published in Nervure identified two fundamentally different types of the syndrome based on previous psychiatric problems and when the symptoms occurred:
- Type 1 [Classic]: These individuals typically have a problematic psychiatric history and may travel to Paris for idiosyncratic “strange” or delusional reasons. However, the onset of the symptoms is immediate upon arrival in Paris (and may even begin in the airport).
- Type 2 [Delayed Expression]: These individuals do not usually have a personal and/or familial psychiatric history. The reasons for visiting Paris are typically for ‘normal’ travelling reasons but the onset of the symptoms is much later than the ‘classic’ type (i.e., three months or longer after arriving in Paris).
As an example of the first type of sufferer, the paper described the case of a 39-year-old Japanese woman with a history of schizophrenia that was hospitalized following a psychotic breakdown on her immediate arrival in Paris. She had come to Paris following an advertizing campaign that had the tagline: “France is waiting for you”. She took it to mean it was her personal destiny to go there and claimed she was going to become the queen of one of the Scandinavian countries (“Sweden, Finland or Denmark”). As an example of the second type of sufferer, the paper described the case of a 30-year-old Japanese man with no previous psychiatric history who came to France for educational reasons. The onset of the symptoms was five months after arriving in France and started when he moved into a Paris hotel (after initially studying in Reims). He was hospitalized after experiencing severe anxiety, insomnia, anorexia, and auditory hallucinations (i.e., voices threatening to kill him and his family).
One of the factors that appear to be common among sufferers is that they appear to be highly unprepared for the reality of day-to-day life in the city (e.g., the marked cultural differences, the great difference in language, the difference in public manners and behaviours, etc.). It is these differences that appear to act as a trigger for the onset of the behaviour. The most salient trigger for Paris Syndrome is thought to be the language barrier. Another factor appears to be intense exhaustion caused by trying to cram in as much as possible in the short time available for sightseeing alongside the effects of jetlag. Such factors are said to contribute to the psychological destabilization of some Japanese visitors. Another French physician (Youcef Mahmoudia) working at the hospital Hotel-Dieu de Paris claimed that Paris Syndrome was “a manifestation of psychopathology related to the voyage, rather than a syndrome of the traveller” and hypothesized that it was the excitement resulting from visiting Paris that caused the psychosomatic symptoms (e.g., increased heart rates, dizziness, etc.).
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Angelique, C. (2006). Paris syndrome hits Japanese. The Guardian, October 25. Located: http://www.guardian.co.uk/world/2006/oct/25/japan.france
Fastovsky N, Teitelbaum A, Zislin J, et al (2000). The Jerusalem syndrome. Psychiatric Services, 5, 1052.
Halim, N. (2009). Mad tourists: The “vectors” and meanings of city-syndromes. In K. White (Ed.), Configuring Madness. Oxford: Inter-Disciplinary Press.
Monden, C. (2005). Development of psychopathology in international tourists. In van Tilburg, M. & Vingerhoets, A. (Eds.), Psychological Aspects of Geographical Moves: Homesickness and Acculturation Stress (pp. 213-226). Amsterdam: Amsterdam Academic Archive.
Tamami, K. (1998). Reflexions on a case of Paris syndrome. Journal of the Nissei Hospital, 26, 127-132.
Viala, A., Ota, H., Vacheron, M.N., Martin, P., & Caroli, F. (2004). Les Japonais en voyage pathologique à Paris: Un modèle original de prise en charge transculturelle. Nervure (supplement), 17(5), 31-34.
Wikipedia (2012). Paris Syndrome. Located at: http://en.wikipedia.org/wiki/Paris_syndrome
Wyatt, C. (December 20, 2006). Paris Syndrome strikes Japanese. BBC News, December 20/ Located at: http://news.bbc.co.uk/1/hi/6197921.stm
In previous blogs I have looked at pica and some of the pica sub-variants including pagophagia (the eating of ice) and coprophagia (the eating of faeces). Pica is defined as the persistent eating of non-nutritive substances for a period of at least one month, without an association with an aversion to food. Today’s blog takes a look at geophagia (the eating of earth, soil and/or clay). In a literature review published in the Journal of the Royal Society of Medicine by Dr Alexander Woywodt and Dr. Akos Kiss that geophagia has been regarded as a psychiatric disease, a culturally sanctioned practice and/or a sequel to poverty and famine. Geophagia is also a culturally sanctioned practice in some parts of the world. Woywodt and Kiss also stated that:
“[Geophagia] is not uncommon in southern parts of the United States5 as well as urban Africa. Fine red clay is often preferred. In particular, geophagia is observed during pregnancy or as a feature of iron-deficiency anaemia. Where poverty and famine are implicated, earth may serve as an appetite suppressant and filler; similarly, geophagia has been observed in anorexia nervosa. However, geophagia is often observed in the absence of hunger, and environmental and cultural contexts of the habit have been emphasized. Finally, geophagia is encountered in people with learning disability, particularly in the context of long-term institutionalization”.
The relationship between anaemia and pica (including geophagia) has been well documented. However, Woywodt and Kiss assert that it is still unclear whether anaemia prompts geophagia to compensate for iron deficiency or whether geophagia is the cause of anaemia. Prevalence rates of pica have range anywhere between 0.02% and 74% depending on the study and population studied although there are few reliable prevalence estimates of geophagia. One study of pregnant Tanzanian women found a prevalence rate of 26.5% (but this is – of course – a totally unrepresentative sample).
A recent review on pica led by Dr Sera Young (University of California, USA) noted that geophagia is the most common type of pica described in the psychological and medical literature although it did also report that geophagics frequently eat other non-food stuffs (particularly if the desired soil is unavailable or socially unacceptable). For many people, pica is not dangerous but for geophagia there may be complications including parasitic infections (from eating soil). Although eating soil and clay may be regarded as unappetizing (and perhaps bizarre) by most people, some authors have argued that eating soil can be nutritionally beneficial (which if that was the case, it wouldn’t technically be a form of pica).
While not being considered a social norm in Western society, eating soil or clay is said to be quite common among primitive or economically depressed peoples a way of augmenting a scanty and/or mineral-deficient diet. Having said that, the geophagia is most often confined to people suffering from chronic mental illness. Clay (as opposed to soil) consumption has been reported in India, Haiti, various parts of Africa (Cameroon, Gabon, Guinea), and even rural areas of the USA. Like soil consumption, clay consumption has also been associated with pregnant women and some women claim they eat it to eliminate nausea. The Wikipedia entry on geophagia noted:
“In Haiti, the poorest economy in the Western Hemisphere, geophagy is widespread. The clay mud is worked into what looks like pancakes or cookies, called ‘bon bons de terres’…The cookies have little or no nutritional value and are associated with various health problems”.
A study led by Dr. L.T. Glickman and colleagues, and published in a 1999 issue of the International Journal of Epidemiology, provided some data on geophagia by carrying out a study examining intestinal parasitism among children from three rural villages in Guinea (Africa). More specifically they examined the faecal stools of 266 randomly selected children (aged 1-18 years). The researchers found that 53% of children were infected by at least one type of soil-transmitted parasite. They also surveyed parents and reported that geophagia was reported by parents to occur in 57% of children aged 1-5 years, 53% of children aged 6-10 years, and 43%, of children aged 11-18 years. It was concluded that geophagia is an important risk factor for orally acquired parasitic infections in African children.
A small study carried out by Turkish researchers and published in a 1978 issue of Acta Haematologica carried out oral iron and zinc tolerance tests on 12 patients from Turkey and Iran aged between 8 and 21 years with iron deficiency anemia and geophagia. The research team reported decreased iron and zinc absorption in patients compared to control patients. They concluded that iron and zinc malabsorption may be an additional feature of the syndrome characterized by geophagia among those from Turkey and Iran. Finally, in their literature review on geophagia, Dr Woywodt and Dr Kiss concluded that:
“The causation is certainly multifactorial; and clearly the practice of earth-eating has existed since the first medical texts were written. The descriptions do not allow simple categorization as a psychiatric disease. Finally, geophagia is not confined to a particular cultural environment and is observed in the absence of hunger”
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Arcasoy, A., Cavdar, A.O. & Babacan, E. (1978). Decreased iron and zinc absorption in Turkish children with iron deficiency and geophagia. Acta Haematologica, 60, 76-84.
Ashworth, M., Hirdes, J.P. & Martin, L. (2008). The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Research in Developmental Disabilities, 30, 512-520.
Danford, D.E. & Huber, A.M. (1982). Pica among mentally retarded adults. American Journal of Mental Deficiency, 87, 141-146.
Glickman, L.T., Camara, A.O., Glickman, N.W. & McCabe, G.P. (1999). Nematode intestinal parasites of children in rural Guinea, Africa: Prevalence and relationship to geophagia. International Journal of Epidemiology, 28, 169-174.
Kettaneh, A., Eclache, V., Fain, O., Sontag, C., Uzan, M. Carbillon, Stirnemann, J. & Thomas, M. (2005). Pica and food craving in patients with iron-deficiency anemia: A case-control study in France. American Journal of Medicine, 118, 185-188
Lacey, E. (1990). Broadening the perspective of pica: Literature review. Public Health Reports, 105, 29-35.
López, L.B., Ortega Soler, C.R. & de Portela, M.L. (2004). Pica during pregnancy: A frequently underestimated problem. Archivos latinoamericanos de nutricion, 54, 17-24.
Nyaruhucha, C.N. (2009). Food cravings, aversions and pica among pregnant women in Dar es Salaam, Tanzania. Tanzania Journal of Health Research, 11(1), 29–34.
Rose, E.A., Porcerelli, J.H, & Anne Neale, A.V. (2000). Pica: Common but commonly missed. Journal of the American Board of Family Practice, 13, 353-358.
Stein, D.J., Bouwer, C. & van Heerden, B. (1996). Pica and the obsessive- compulsive spectrum disorders. South African Medical Journal, 86, 1586-1592.
Woywodt, A. & Kiss, A. (2002). Geophagia: the history of earth-eating. Journal of the Royal Society of Medicine, 95:143-146.
Young, S.L., Wilson, M.J., Miller, D., & Hillier, S. (2008). Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS One, 3(9), e3147.
Wikipedia (2012). Geophagy. Located at: http://en.wikipedia.org/wiki/Geophagy
In previous blogs I have examined various culture bound syndromes (CBSs) such as koro and berserkers. CBSs comprise a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies and are often unknown outside of their own local regions. One of the more unusual CBSs is dhat syndrome, typically located in the Indian sub-continent (India, Sri Lanka, Bangladash). Dhat is one of the CBSs listed in the World Health Organization’s International Classification of Diseases.
The term ‘Dhat syndrome’ was first described by Dr. N.N. Wig in a 1960 issue of the (Indian) Journal of Clinical and Social Psychiatry, and then by Dr. J.S. Neki in the British Journal of Psychiatry (1973). A 1975 paper by Dr. H.K. Malhotra and Dr. N.N. Wig in the Archives of Sexual Behavior called dhat “the exotic neurosis of the Orient”. According to a short paper by Dr. Om Prakash in the Indian Journal of Psychiatry, dhat syndrome comprises various psychological, somatic and sexual symptoms attributed by the patient to the passing of whitish fluid, believed to be semen in urine (i.e., psychological distress and anxiety related to semen-loss). Prakash says that the word ‘dhat’ is derived from the Sanskrit word ‘dhatu’ (which has multiple meanings including ‘metal’, ‘elixir’ and ‘constituent part of the body’). He also noted that:
“This notion of seminal loss frightens the individual into developing a sense of doom if a single drop of semen is lost, thereby producing a series of somatic symptoms…fear of semen loss and resulting problems [in India] is so strong that cures are advertised by vaids and hakims everywhere – on walls, on television, in newspapers and on roadside hoardings”.
The anxiety surrounding the semen loss can also relate to the releasing of semen via nocturnal emissions (i.e., ‘wet dreams’) and masturbation. The symptoms include fatigue, listlessness, appetite loss, lack of physical strength, poor concentration, forgetfulness, guilt, and (in some cases) sexual dysfunction. Given the syndrome relates to psychological anxiety surrounding semen loss, the disorder is (necessarily) found among men, but interestingly, the dhat syndrome has also been applied to women who experience similar symptoms relating to white vaginal discharge). According to an online article on CBSs, it claims that:
“The anxiety related to semen loss can be traced back thousands of years to Ayurvedic texts, where the loss of a single drop of semen, the most precious body fluid, could destabilize the entire body”
A 2004 literature review on dhat syndrome by Dr. A. Sumathipala and colleagues in the British Journal of Psychiatry speculated that the disorder was a “hypochondriacal preoccupation”. This may have some validity as a 1990 paper by Dr. R.K. Chadha and Dr. N. Ahuja (also in the British Journal of Psychiatry) reported a study of 52 dhat patients. Three-quarters of their sample were reported as having hypochondriacal symptoms.
Another study in the British Journal of Psychiatry a year later by Dr. M.S. Bhatia and Dr. S.C. Malik reported that 93 (out of 144) consecutive patients attending a sexual dysfunction clinic had dhat syndrome. A number of papers published on the dhat syndrome in the 1980s and 1990s all report that depressive, anxiety and/or somatoform disorders are prevalent in the majority of dhat sufferers. A small 1989 Sri Lankan study by Dr. P. De Silva and Dr. S. Dissanayake in the Sexual and Marital Therapy journal on 38 men with sexual dysfunction, reported that ‘semen loss’ was seen by most of the men as the main reason for their sexual dysfunction. The same study reported that 40% of the sample had hypochondriasis. Similar findings have been reported among Bangladeshi men. (It should also be noted that there are various reports of similar syndromes in other countries. For instance, Prakash’s paper also mentions ‘shen-k’uei’ in Taiwan and China which from the symptoms listed appear almost identical to dhat)
Based on papers published in the British Journal of Psychiatry and Indian Journal of Psychiatry (mainly from the 1980s and 1990s), Prakash presents a profile of those affected with dhat and claims that most are young males, recently married, from rural areas, low to average socioeconomic status (farmers, labourers, farmers), and from families with conservative attitudes towards sex. He also claims (seemingly based on a 2001 book chapter by by Dr. A. Avasthi and Dr. R. Nehra) that there are three types of dhat patients:
- Dhat alone (where their symptoms are attributed to semen loss, and with presenting symptoms that are hypochondriacal, depressive or anxiety-related in nature)
- Dhat with comorbid depression and anxiety (where dhat is seen as a symptom accompanying another disorder)
- Dhat with sexual dysfunction
The duration of the symptoms can be relatively short-lived (e.g., 3-12 months) but some papers report people suffering for up to 20 years. Prakash lists the most common co-morbid disorders and sexual dysfunctions associated with dhat. This included depressive neurosis (40%-42%), anxiety neurosis (21%-38%), somatoform and hypochondriasis (32%-40%), erectile dysfunction (22%-62%), and premature ejaculation (22%-44%). Prakash also reports that the majority (i.e., two-thirds) of dhat sufferers recover (66%), with the remainder either improved (22%) or unchanged (12%). Finally, the most recently published paper on dhat syndrome by Dr. Neena Sanjiv Sawant and Dr. Anand Nath in a 2012 issue of the Sri Lankan Journal of Psychiatry noted that dhat beliefs are often based on misconception and myths:
“These myths and misconceptions which are deeply rooted in Indian culture are passed from generation to generation. Due to the lack of proper information and lack of open communication between parents and children, the only source of knowledge for many remain their peers, who are equally ignorant about the subject, and this leads to widespread misconceptions. Many people consult unqualified practitioners who reinforce their ignorance”
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Avasthi, A. & Nehra, R. (2001). Sexual disorders: A review of Indian Research. In: Murthy, R.S. (Ed.), Mental Health in India (1995-2000) (pp.42-53). Bangalore: People’s Action for Mental Health.
Behere, P.B., Natraj, G.S. (1984). Dhat syndrome: The phenomenology of a culture-bound sex neurosis of the orient. Indian Journal of Psychiatry, 26, 76-78.
Bhatia, M.S. & Malik, S.C. (1991). Dhat Syndrome – A useful diagnosis entity in Indian Culture. British Journal of Psychiatry, 159, 69-75.
Chadda, R.K. & Ahuja, N. (1990). Dhat syndrome: A sex neurosis of the Indian subcontinent. British Journal of Psychiatry, 156, 577-579.
De Silva, P. & Dissanayake, S.A.W. (1989) The loss of semen syndrome in Sri Lanka. A clinical study. Sexual and Marital Therapy, 4, 195-204.
Malhotra, H.K. & Wig, N.N. (1975). A culture bound sex neurosis in the Orient. Archives of Sexual Behaviour, 4, 519-528.
Neki, J.S. (1973). Psychiatry in South East Asia. British Journal of Psychiatry, 123, 257-269.
Prakash, O. (2007). Lessons for postgraduate trainees about Dhat syndrome. Indian Journal of Psychiatry, 49, 208–210.
Sawant, N.S. & Nath, A. (2012). Cultural misconceptions and associated depression in Dhat syndrome. Sri Lankan Journal of Psychiatry, 3, 17-20.
Sumathipala, A. Siribaddana, S.H. & Bhugra, D. (2004). Culture-bound syndromes: The story of dhat syndrome. British Journal of Psychiatry, 184, 200-209.
Wig, N.N. (1960). Problems of mental health in India. Journal of Clinical and Social Psychiatry (India), 17, 48-53.
In previous blogs I have examined various culture bound syndromes (i.e., a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies). Arguably, one of the most interesting culture bound syndromes is (the much disputed) ‘Windigo psychosis’ that was said to have been reported among Algonquian native tribes (which are among the biggest and most widespread of North American natives and who lived around the Great Lakes of Canada and America). The disorder allegedly comprised individuals who intensely craved human flesh and who believed they would turn into cannibals.
The windigo was a cannibalistic spirit forest creature that appeared in Algonquian legends, and was known by lots of other names and variants (including – among 37 others identified by John Columbo in his 1982 book Windigo – wendigo, weendigo, windiga, waindigo, windago, wihtikow, and witiko). For instance, the Ojibwa tribe (a Native American people originally located north of Lake Huron before moving westward in the 17th and 18th centuries into Michigan, Wisconsin, Minnesota, western Ontario, and Manitoba) believed the windigo was a ferocious ogre that took children away if they did not behave themselves. More generally, it was believed that the windigo could possess and infect human beings and transform them into cannibalistic creatures. Such cannibalistic practices were said to have begun in times of extreme winter famine when families were isolated and confined to their cabins because of heavy snowfall. Legend also has it that the infected sufferer would have their heart turned to ice.
However, windigo is a disorder that has been continually challenged across many decades as a myth (for instance, Dr. R.H. Prince in a 1992 issue of Transcultural Psychiatric Research Review; Dr. R.C. Simons and Dr. C. Hughes in a 1993 book chapter on culture bound syndrome; Dr. P.M. Yap in a 1967 issue of the Australia New Zealand Journal of Psychiatry). Whether the condition genuinely existed or not, no-one disputes that the number of cases reported over the last hundred years are minimal.
According to John Columbo, the first derivation of the word ‘windigo’ (i.e., the word ‘onaouientagos’ meaning both ‘cannibal’ and ‘evil spirit’) first appeared in print as long ago as 1722 in an account by Bacqueville de la Potherie, a French traveler. Windigo psychosis was said to occur when an individual became highly anxious that they were transforming into a windigo and believed that other humans that they lived among them were edible. Symptoms of the psychosis were said to include nausea, vomiting, poor appetite and anti-social behaviour. In extreme cases, the psychosis was said to produce suicidal tendencies (as a way of preventing possession by the windigo) and/or homicidal tendencies (to eat the human flesh of others). A book (The Lost Valley and Other Stories) written by Algernon Blackwood in 1910 featured a horror story (called ‘The Wendigo’), and was widely believed to be based on the Algonquian windigo legends.
In the 1982 book Windigo: An Anthology of Facts and Fantastic Fiction edited by John Columbo, he noted that:
“Windigo has been described as the phantom of hunger which stalks the forests of the north in search of lone Indians, halfbreeds, or white men to consume. It may take the form of a cannibalistic Indian who breathes flames. Or it may assume the guise of a supernatural spirit with a heart of ice that flies through the night skies in search of a victim to satisfy its craving for human flesh. Like the vampire, it feasts on flesh and blood. Like the werewolf, it shape-changes at will”.
In an online article about ‘culture specific diseases’, Denis O’Neil claims that modern medical diagnoses might label windigo as a form of paranoia because “of the irrational perceptions of being persecuted”. Here, O’Neil argues that it is the windigo monsters who are the persecutors (i.e., the windigo monsters are trying to turn people into monsters like themselves). O’Neil also argues that in contemporary North American culture “the perceived persecutors of paranoids are more likely to be other people or, perhaps, extra terrestrial visitors”.
Writing in a 2006 issue of the journal Transcultural Psychiatry, Dr. Wen-Shing Tseng said that it’s important to re-examine the sources of knowledge for each culture-related specific syndrome (including windigo which she also examined). She acknowledged that literature relating to windigo dated back to the 17th century, she made a lot of reference to the work of J.E. Saindon and the Reverend J.M. Cooper who both worked among an Algonquian community in the 1930s. She argued that the reports of both Saindon and Cooper “were based on second-hand information provided by non-clinical observers”. She then noted that the pioneering cultural psychiatrists of the 1950s and 1960s dealt with these early accounts “as though they were well-defined clinical entities with the diagnostic term witiko psychosis”.
In a paper by Dr. Lou Marano in a 1982 issue of Current Anthropology, it was noted that aspects of the Windigo belief complex may have had components in some individual’s psychological dysfunction. However, he concluded that after (i) five years’ field experience among Northern Algonquians, (ii) extensive archival research, and (iii) a critical examination of the literature:
“There probably never were any windigo psychotics in an etic/behavioral sense. When the windigo phenomenon is considered from the point of view of group sociodynamics rather than from that of individual psychodynamics, the crucial question is not what causes a person to become a cannibalistic maniac, but under what circumstances a Northern Algonquian is likely to be accused of having become a cannibalistic maniac and thus run the risk of being executed as such”.
In essence, Marano’s conclusion was that windigo psychosis was simply an artifact of research that was conducted without sufficient knowledge of the indigenous experience.
Colombo, J.R. (1982). Windigo: An Anthology of Facts and Fantastic Fiction. Lincoln: University of Nebraska Press.
Marano, Lou (1982). Windigo psychosis: The anatomy of an emic-etic Confusion. Current Anthropology, 23, 385-412.
O’Neil, D. (2010). Culture specific diseases. October 7. Located at: http://anthro.palomar.edu/medical/med_4.htm
Prince, R. H. (1992). Koro and the Fox Spirit on Hainan Island (China). Transcultural Psychiatric Research Review, 29(2), 119-132.
Simons, R. C., & Hughes, C. (1993). The culture bound syndrome. In A. Gaw (Ed.). Culture, Ethnicity and Mental Illness (pp. 75–99). Washington, DC: APA.
Tseng, W-S. (2006). From peculiar psychiatric disorders through culture-bound syndromes to culture-related specific syndromes. Transcultural Psychiatry, 43; 554-576.
Wikipedia (2012). Wendigo. Located at: http://en.wikipedia.org/wiki/Wendigo
Yap P. M. (1967). Classification of the culture-bound reactive syndromes. Australia New Zealand Journal of Psychiatry, 1, 172-179.
Yap, P. M. (1969). The culture bound syndromes. In W. Cahil., & T. Y. Lin. (Eds.). Mental Health Research in Asia and the Pacific (pp. 33-53). Honolulu: East West Centre Press.
In a previous blogs I have examined both Celebrity Worship Syndrome and whether fame can be addictive. Another behaviour allied to both of these is celebriphilia. There has been no scientific research on celebriphilia and I have only come across a few passing references to it in academic texts. In his 2009 book Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices, Dr Anil Aggrawal describes it as a sexual paraphilia where a “pathological desire to have sex with a celebrity”. The online Medical Dictionary is slightly different and defines celebriphilia as “an intense desire to have a romantic relationship with a celebrity” (and is therefore slightly different is the focus on this second definition is romance rather than sex, although there is an implicit assumption that having romantic relationship would involve sex). Finally, the only other definition that I have come across is in the online Nation Master encyclopedia that was a bit more padded out and claimed that:
“Celebriphilia is the sexual fetishism and obsession with sex with a celebrity or famous person. Celebriphiliacs may stalk these celebrities and either observe them for sexual pleasure voyeuristically or try and approach them and have sex with them. Some may simply masturbate to images of them”
Despite this more in-depth definition, it actually complicates matters as it brings in other behaviours such as voyeurism and stalking that are separate entities in and of themselves. As far as I can tell, the first reference to ‘celebriphilia’ appeared in an article written by journalists Benjamin Svetkey and Allison Hope Weiner for Entertainment Weekly. Their article was about Bonnie Lee Bakley, the wife of American actor Robert Blake (star of shows like Baretta and films such as In Cold Blood), who was shot in 2001 (May 4) while sitting outside a Los Angeles restaurant in Blake’s car. (Blake was eventually charged with his wife’s murder but was found not guilty. The murder remains officially unsolved although Bakley’s grown-up children from previous relationships took out a civil suit on Blake and was later found guilty of wrongful death).
The focus of the article by Svetkey and Weiner was Bakley’s celebriphilia and her ‘celebrity obsession’ (more specifically, her long-term history of pursuing relationships with celebrities). Bakley’s close friends all stated that her aim in life was to marry someone famous and all of her actions were geared around achieving this goal. Bakley was quoted as saying “being around celebrities makes you feel better than other people”. Her pursuing of celebrities began in 1990 when she became obsessed with wanting to marry rock ‘n’ roll singer Jerry Lee Lewis. She even moved to Memphis where Lewis was living, met him, and befriended Lewis’ sister as a way of getting closer to him. Bakley may have had a brief sexual relationship with Lewis, and in 1993 she gave birth to a daughter and claimed Lewis was the father (and even went as far as to name the baby Jeri Lee). Paternity tests later proved that Lewis was not the father of Bakley’s daughter. Following a move from Memphis to California, she continued her celebrity obsession by pursuing many different celebrities including actor Gary Busey, singer-songwriter and guitarist Chuck Berry, singer Frankie Valli, actor Robert De Niro, singer-songwriter Lou Christie, publisher Larry Flynt, entertainer Dean Martin, and musician Prince, before having a relationship with Marlon Brando’s son, Christian (following his release from prison in 1996).
It was in 1999, that Bakley met American actor Robert Blake while still dating Brando. She became pregnant again (telling both Blake and Brando that they were the father of the baby). She believed Brando was the father of the daughter she gave birth to (naming the child Christian Shannon Brando). However, later paternity tests showed it was Blake who was the father (and the baby was then re-named Rose). In November 2000, Bakley and Blake married (and Blake became Bakley’s tenth [!!!] husband). When I first read about Bakley’s attempts to have a relationship with someone famous, the first words that sprang to mind was ‘groupie’ and ‘stalker’. However, the article by Svetkey and Weiner specifically stated that:
“People who attempt to make themselves ”feel better” by romantically pursuing the famous [are] not groupies: Groupies are merely overzealous, oversexed fans. They’re not stalkers, either. Bakley’s relationship with Blake wasn’t imaginary…nor is she known to have ever threatened him with physical harm. And although her past was hardly squeaky-clean…she wasn’t simply a grifter. What Bakley pursued with meticulous and methodical precision wasn’t so much cash as cachet, the reflected glory of being with a star. Any star would do — even one like Blake, who hasn’t shone for the better part of a decade. Unlike stalkers and groupies, people like Bakley generally don’t develop crushes on the stars they pursue — it’s fame itself that flames their desires, regardless of whom it’s attached to. Sometimes they don’t even seem to like those they’re chasing. While Bakley was attempting a relationship with Blake, for instance, she was also apparently involved with Marlon Brando’s son Christian”.
Most of the famous people that she pursued most actively (i.e., Blake, Brando, Lewis) had careers that were on the wane. She chose people that wanted validation that they were still famous. Both Bakley and the ‘stars’ she chased appeared to be yearning validation, attention and wanting to be perceived as special. An American psychotherapist – Donald Fleming – was interviewed for the article by Svetkey and Weiner. He speculated about celebriphiles:
”Often these people have serious identity problems. They lack a centered sense of self. They’re usually people that have not developed any particular skills or abilities in life. They never developed out of their grandiose childhood wishes and fantasies to be important. The only way they can feel important or special or unique is through famous people being part of their life…People who follow stars often have the obsessive-compulsive trait. They can fool almost anybody. They become so acute at reading how to meet another person’s needs that they can pick up on their vulnerabilities and play them like a violin”.
Dr. David Giles who wrote one of the best books on the psychology of fame – Illusions of Immortality: A Psychology of Fame and Celebrity – explains the relationships that people have with celebrities as a parasocial interaction:
”One of the things about fame is how incredibly new it is to human experience. It started with mass communication, which is only about 100 years old. And the speed with which it’s developed – radio and then TV – has been astonishing. In an evolutionary sense, we may not have caught up with the phenomenon of fame as a species”.
Celebrity (and therefore celebriphilia) is as Dr. Giles would argue a completely modern, man-made phenomenon. In typical journalese, Svetkey and Weiner wrote that celebrity has “been injected into the cultural bloodstream like an untested drug – with a similar rush of disorienting results”. They also speculate about other people that display celebriphilia:
“Courtney Love may have once suffered a touch of it. (‘Become friends with Michael Stipe’, Kurt Cobain’s widow supposedly jotted in a journal years ago, mapping her road to fame)…And certainly Whitney Walton – known around Hollywood as the mysterious ‘Miranda’ – has something like it. She became infamous for charming her way into telephone friendships with Billy Joel, Warren Beatty, Quincy Jones, Richard Gere, and…other celebrities [including] Robert De Niro”.
As noted above, there has been no empirical research on celebriphilia unless you include the small amount of research on ‘celebrity stalking’ (although very few academics who have written on the topic use the word ‘celebriphilia’). However, there are a few exceptions. For instance, Dr. Brian Spitzberg and Dr. Michelle Cadiz wrote a paper on the media construction of stalking stereotypes and described one of the types as ‘stalking as celebriphilia’ in a 2002 issue of the Journal of Criminal Justice and Popular Culture (although the authors didn’t actually define what celebriphilia was in this context). In a 2006 book (Constructing Crime: Perspectives on Making News and Social Problems) edited by Dr. Victor Kappeler and Dr. Gary Potter, the authors briefly noted (in what seems a follow on from the paper by Spitzberg and Cadiz) that “media reports eventually moved away from a dominant image of stalkers as exclusively experiencing ‘celebriphilia’”.
Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.
Giles, D. (2000). Illusions of Immortality: A Psychology of Fame and Celebrity. London: Palgrave Macmillan.
Kappeler, V.E. & Gary W. Potter, G.W. (2006). Constructing Crime: Perspectives on Making News and Social Problems. Prospect Heights, IL: Waveland Press.
King, G. (2011). Who murdered Bonny Lee Bakley? (part 7: Bony the celebriphiliac). Crime Library, Located at: http://www.trutv.com/library/crime/notorious_murders/family/bakley/7.html
Medical Dictionary (2012). Celebriphilia. Located at: http://medical-dictionary.thefreedictionary.com/Celebriphilia
Nation Master (2012). Celebriphilia. Located at: http://www.nationmaster.com/encyclopedia/Celebriphilia
Spitsberg, B.H. & Cadiz, M. (2002). The media construction of stalking stereotypes. Journal of Criminal Justice and Popular Culture, 9(3), 128-149.
Svetkey, B. & Weiner, A.H. (2001). Dangerous game. Entertainment Weekly, June 22. Located at: http://www.ew.com/ew/article/0,,256019,00.html
Wiktionary (2012). Citations: Celebriphilia. Located at: http://en.wiktionary.org/wiki/Citations:celebriphilia
I have to admit that I know relatively little about the neuropsychology of hallucinations. The only time I have written about them in scientific journals is in the context of excessive video gaming where there are case studies of people who appear to display auditory and/or visual game-related hallucinations, and may be part of a wider repertoire of sensory consequences of video game playing that we have coined ‘game transfer phenomena’ (and which I outlined in a previous blog).
However, in a completely different context, I recently came across a really interesting 2011 case study by Dr. Amin Gadit who published a short paper in BMJ Case Reports entitled ‘Insightful hallucination: psychopathology or paranormal phenomenon?’ Dr. Gadit noted that hallucinations are usually indicative of a serious psychiatric problem (i.e., typically some kind of psychosis) and typically require treatment. However, Dr. Gadit described the case of a 26-year old successful Pakistani businessman who was suffering hallucinations but experienced a dilemma as to whether to treat him or not because his hallucinations appeared to be providing some therapeutic benefit to his patient.
The man was married to his first cousin (also from Pakistan) and was described as being “extremely close” to his mother. Dr. Gadit reported that his patient’s wife sometimes got extremely upset (which I interpreted as being jealous) about her husband’s attachment to his mother. Following the mother’s diagnosis of a terminal illness with only a few months left to live, the man (understandably given the relationship with his mother) experienced deep emotional turmoil and upset. Dr. Gadit wrote that according to his patient that:
“[His] mother told him before dying that she would remain in contact with him after death. The patient went through a complicated bereavement period when she died. However, 6 months later, he regained his cheerful mood and started taking an interest in business again. His wife noticed that he was talking to himself for at least an hour each day. When asked, he said that his mother visits him every day and he talks to her. This was his firm belief. There was no deterioration in his personality and no other features worthy of note”.
Following these episodes of speaking to his dead mother almost every night at different times in the evening, the man’s wife persuaded him to seek psychiatric help. Dr. Gadit claimed that his patient resented being in treatment and argued that the regular “contact” with his dead mother was a positive experience and made the man happy and helped bring normality to his day-to-day life. Following initial psychiatric assessment, Dr. Gadit noted that:
“There was no significant medical history or family history indicative of any mental disorder. A thorough clinical history revealed nothing except this hallucination. The patient had retained insight as he believed that this would not happen normally but in his case was a special occurrence. He attributed this to his Muslim belief of God’s blessing in sending his mother back to him in this way. His physical examination was unremarkable and all laboratory results were normal. MRI did not reveal any pathology. His mental state examination revealed normothymic mood, delusion, visual hallucination, psychosis (with no supporting evidence), intact cognitive function and reasonable insight into his problem”.
The man’s mother appeared most evenings wearing different dresses (ones that she used to wear when she was alive) but he said his mother would not allow him to touch her when she appeared. The man was adamant that his mother appeared before him in the real world and refused any medical treatment. Organ pathology (often associated with auditory hallucinations) was ruled out as a cause, and there was insufficient evidence for a diagnosis of schizophrenia (often associated with auditory hallucinations). Ultimately, Dr. Gadit did not reach a psychiatric diagnosis and he sought a second opinion (which also failed to produce a diagnosis). The lack of formal diagnosis posed a dilemma in terms managing the presenting condition. The man had monthly appointments for over half a year with Dr. Gadit but the condition remained constant. In discussing the case, Dr. Gadit wrote that:
“The patient recognises the hallucination (perception without the presence of an external stimulus) as happening in the real world. It is important to differentiate true hallucination from ‘pseudo-hallucination’ and ‘imagery’. A pseudo-hallucination is an involuntary sensory experience vivid enough to be regarded as a hallucination but recognised by the patient as not the result of external stimuli; it would not be considered by the person to be ‘real’. Imagery is a collection of images used to create a sensory experience and is the element in a literary work used to evoke mental images and stimulate an emotional response. In the current case report, the patient believes that he can see and talk to his mother in the real world and that he is not imagining it”.
In discussing the case in relation to previous literature, Gadit made reference to a 2009 paper by H. Haween in the Dartmouth Undergraduate Journal of Science (DJUS) that reported hallucinations following bereavement typically resolve over time. Such hallucinations are most commonly in reported during the grieving process in males aged 25 to 30 years. Other similar non-psychiatric illnesses include Charles Bonnet’s Syndrome (typical sufferers being the elderly) that comprises clear hallucinations experienced among visually impaired individuals. A study dating back to 1971 by Dr. W.D. Rees and published in the British Medical Journal reported ‘widowhood hallucinations’ in 14% of Welsh widows and widowers (n=293). A more recent study in a 2002 issue of the British Journal of Psychiatry, a team led by Dr. L.C. Johns reported a 4% prevalence of hallucinations in white and ethnic minority populations and suggested that hallucinations are not always associated with psychotic disorders.
Gadit claimed that his male case study was “unique” as the persistent hallucinations resulted in no noticeable psychopathology, and appeared beneficial to his patient. He also speculated that the visions might be a paranormal experience or “a case of hallucinosis with a secondary delusional explanation”. Gadit claimed that paranormal phenomena are fairly common in both the developed and the developing world (and typically associated with rituals and myths).
Gadit, A.A.M. (2011). Insightful hallucination: psychopathology or paranormal phenomenon? BMJ Case Reports 2011; doi:10.1136/bcr.10.2010.3456
Heewan K. (2009). Hallucination: a normal phenomenon? Dartmouth Journal of Undergraduate Science, November 21. Located at: http://dujs.dartmouth.edu/fall-2009/hallucination-a-normal-phenomenon
Johns, L.C., Nazroo, J.Y., Bebbington, P., et al. (2002). Occurrence of hallucinatory experiences in a community sample and ethnic variations. British Journal of Psychiatry, 180, 174-178.
Menon, G.J., Rahman, I. & Menon, SJ, et al. (2003) Complex visual hallucinations in the visually impaired: the Charles Bonnet Syndrome. Survey of Ophthalmology, 48, 58-72.
Ortiz de Gotari, A., Aronnson, K. & Griffiths, M.D. (2011). Game Transfer Phenomena in video game playing: A qualitative interview study. International Journal of Cyber Behavior, Psychology and Learning, 1(3), 15-33.
Rees, W.D. (1971). The hallucinations of widowhood. British Medical Journal, 4, 37-41.
Spence, S. A. (1993). Nintendo hallucinations: A new phenomenological entity. Irish Journal of Psychological Medicine, 10, 98–99.
Arguably one of the world’s most abhorrent surgical and/or ritualistic practices is the removal of the clitoris, i.e., a clitoridectomy (sometimes referred to as a clitorectomy). Apart from cases of medical necessity (e.g., the spreading of cancer to the clitoris), the vast majority of occurrences can really be best described as female genital mutilation and defined by the World Health Organisation (WHO) as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons”. In societies where clitoridectomies are performed as part of tribal rituals (such as those by the Maasai in Kenya and Northern Tanzania), the main reason for them is by male societies trying to inhibit the act of female masturbation.
According to the World Health Organisation’s online report about female genital mutilation (FGM), clitoridectomies have no health benefits for females, that approximately 140 million girls and women worldwide (but mostly in Africa where about three million girls are at risk for FGM annually.) have been genitally mutilated (usually between infancy and 15 years old), and that FGM is mostly carried out by “traditional circumcisers” although there is a increasing trend for it to be carried out by health care providers (over 18% according to the WHO). They also note that FGM can be classified into four major types: (which I have reproduced verbatim from their report):
- Clitoridectomy: Partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
- Excision: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are “the lips” that surround the vagina).
- Infibulation: Narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris.
- Other: All other harmful procedures to the female genitalia for non-medical purposes (e.g. pricking, piercing, incising, scraping and cauterizing the genital area).
The WHO report also briefly examined the cultural, religious and social causes of FGM. The WHO noted:
“The causes of female genital mutilation include a mix of cultural, religious and social factors within families and communities. Where FGM is a social convention, the social pressure to conform to what others do and have been doing is a strong motivation to perpetuate the practice. FGM is often considered a necessary part of raising a girl properly, and a way to prepare her for adulthood and marriage. FGM is in many communities believed to reduce a woman’s libido and therefore believed to help her resist ‘illicit’ sexual acts….FGM is associated with cultural ideals of femininity and modesty, which include the notion that girls are ‘clean’ and ‘beautiful’ after removal of body parts that are considered ‘male’ or ‘unclean’. Local structures of power and authority, such as community leaders, religious leaders, circumcisers, and even some medical personnel can contribute to upholding the practice”
In a recent (2012) issue of medical journal The Lancet, Dr. Pierre Foldes and his colleagues assessed the immediate and long-term outcomes of reconstructive surgery following genital mutilation. They surveyed 2,938 females (consecutive cases between 1998 and 2009 with an average age of 29 years; 866 of them were re-surveyed at a one-year follow-up interview) that had received reconstructive surgery at the Poissy-St Germain Hospital (in France) following genital mutilation. Most of the women operated upon were from Africa (Senegal, Mali and the Ivory Coast) although Foldes and his colleagues reported that 564 of the women had been genitally mutilated while living in France. The authors reported:
“Expectations before surgery were identity recovery for 2933 patients (99%), improved sex life for 2378 patients (81%), and pain reduction for 847 patients (29%). At 1-year follow-up, 363 women (42%) had a hoodless glans, 239 (28%) had a normal clitoris, 210 (24%) had a visible projection, 51 (6%) had a palpable projection, and three (0·4%) had no change. Most patients reported an improvement, or at least no worsening, in pain (821 of 840 patients) and clitoral pleasure (815 of 834 patients). At 1 year, 430 (51%) of 841 women experienced orgasms. Immediate complications after surgery (haematoma, suture failure, moderate fever) were noted in 155 (5%) of the 2938 patients, and 108 (4%) were briefly re-admitted to hospital”.
On the basis of these findings, Dr. Foldes’ report concluded that the reconstructive surgeries that had been carried out following female genital mutilation appeared to be associated with both reduced pain and restored pleasure (including the ability to have clitoral orgasms).
The vast majority of FGM occurs as a result of third party intervention. However, there are a few isolated cases of clitoral/labial self-mutilation in the clinical and medical literature. (I also examined more general female genital self-mutilation in a previous blog particularly in relation to internal vaginal self-mutilation). A recent paper by Dr. David Veale and Joe Daniels published in a 2012 issue of the Archives of Sexual Behavior examined what they believe is the only case of a women who wanted a clitoridectomy for cosmetic reasons. Prior to this case, they noted that there had been only two previous reports in the literature of self-mutilation of the clitoris/labia (one by Dr. Krasucki and colleagues in a 1995 issue of the British Journal of Medical Psychology and Dr. Wise and colleagues in a 1989 issue of the Journal of Sex and Marital Therapy). Both of the women in these cases of clitoral/labial self-mutilation were associated with severe psychosis/schizophrenia. Veale and Daniels reported that:
“The patient was a 33-year-old married woman with two children who lived with her husband. She was not from a culture that conducted FGM but she believes she was taught about it at school…She can remember starting to dislike her genitalia and pubic hair very gradually since about the age of 13. As she was at boarding school, it was not possible to shave her pubic hair until she left at the age of 18…Her motivation for shaving was a desire for ‘’simplicity and bareness’. She had continued to wax and shave her pubic hair for the past 14 years and was in the process of permanent hair removal, feeling it was more hygienic as well as preferred by her husband. Her dislike of her genitalia continued to increase gradually during adolescence with the growth of secondary sexual characteristics, including the labia minora. The changes in the labia minora became more pronounced with pregnancy and birth of two children born vaginally…She had tried piercing her inner labia and clitoral hood as a form of distraction. However, she found the piercings uncomfortable, which drew further attention to her dislike, so she removed them. Cosmetic labiaplasty had been performed about 1 year prior to assessment. She reported this as much improving the cosmetic appearance of her genitalia and reducing her self-consciousness.
She had become aware that she could do something surgically about her genitalia from her late teens. She had no concerns about the rest of her body and had had no other cosmetic procedures in her lifetime. When assessed, she knew that the appearance of her genitalia looked normal, but she felt they were ugly and hated the look of them. However, her concerns did not amount to a preoccupation (one of criteria for a diagnosis of body dysmorphic disorder…She felt self-conscious in a swimsuit and would not use public changing rooms. She denied that she was being coerced towards surgery or that any sadomasochism was involved…She understood that a clitoridectomy could lead to anorgasmia. However, she believed that the orgasms she experienced during intercourse or by masturbation were mainly vaginal and not clitoral. Improving the aesthetics of the genitalia was more important to her than achieving orgasm and would reduce her anxiety in sexual intimacy…In summary, she had a longstanding aversion to her genitalia associated with an extreme desire for a cosmetic procedure. Such a request, in the absence of any cultural beliefs, would suggest to most clinicians that a patient was very disturbed. However…she had no evidence of any psychiatric disorder or personality disorder”.
Following a full psychiatric check and interviews with the woman’s husband, a clitoridectomy was performed. Veale and Daniels were fully aware that the request for a voluntary clitoridectomy was extremely rare and unusual. However, the post-operative, the woman was extremely grateful and satisfied with the results (even at follow-up nearly two years later). She reported that her sex life had improved and there was no desire to modify any other part of her body. They concluded that although cases of wanting voluntary clitoridectomy are exceedingly rare, there is always the possibility that in the future others may seek such a procedure on cosmetic grounds but that those wanting such a radical operation will require very careful assessment before any operation took place.
Foldes, P., Cuzin, B. & Andro, A. Reconstructive surgery after female genital mutilation: a prospective cohort study. The Lancet, 380, 134-141.
Krasucki, C., Kemp, R., & David, A. (1995). A case of female genital self- mutilation in schizophrenia. British Journal of Medical Psychology, 68, 179–186.
Veale, D. & Daniels, J. (2012). Cosmetic clitoridectomy in a 33-year-old woman. Archives of Sex Behavior, 41, 725-730.
Wikipedia (2012), Clitoridectomy. Located at: http://en.wikipedia.org/wiki/Clitoridectomy
Wise, T. N., Dietricha, M., & Segalle, E. (1989). Female genital self- mutilation: Case reports and literature review. Journal of Sex and Marital Therapy, 15, 269–274.
World Health Organisation (2012). Female genital mutilation (Fact Sheet 241), February. Located at: http://www.who.int/mediacentre/factsheets/fs241/en/
When I was a kid (well about 12 or 13 years old) my friends and I used to occasionally play a game that we called ‘Headrush’ where I would have my breathing temporarily stopped by someone holding onto my chest after a deep expiration and hyperventilation (so that I couldn’t breathe), and it would induce feelings of light-headedness and dizziness followed by temporary unconsciousness (usually lasting 10-15 seconds). I did it twice and on both occasions I felt as though I had lived a whole other life while I was unconsciousness. I’m not condoning the behaviour (as it’s potentially life-threatening) but the experience was pretty mind-blowing (at least that’s my adolescent recollection). The only thing I can relate it to are the accounts I have read by others who have talked about their near death experiences.
I vividly remember the day that I said I would never do it again as my friends and I thought we had caused the death of another boy (a couple of years older than ourselves). My best friend at the time had induced the fainting reaction in our older friend and he was out cold for much longer than the 10-15 seconds we would normally have expected. We thought he was dead. However, after about 25-35 seconds our friend’s hands and feet were making strange movements. I remember his feet ‘clapping’ together constantly for about 20 seconds. After about a minute he came around and said that he had experienced a wonderful feeling that he had lived his life as a seal! Despite the fact that my friend lived to tell the tale, I never participated in the fainting game ever again.
I had not even thought about these adolescent experiences until a few months ago until I came across (quite by chance) a paper written by Dr. Gil Shlamovitz and colleagues on ‘suffocation roulette’ in a 2003 issue of Annals of Emergency Medicine. They reported the case of a 12-year-old boy admitted to hospital because of “recurrent syncopal episodes” (i.e., persistent fainting). The authors reported that the fainting episodes were due to a game they called ‘suffocation roulette’ (a term I had not heard before but was the same game that I described above). After reading this paper, I decided I would have a further look into this phenomenon and it became very clear that the game I played as a young teenager has been played by many others around the world (under dozens of different names that I’ve listed at the end of this blog). It also appears that what we were doing as kids was a form of ‘self-induced hypocapnia’ that refers to a state of reduced carbon dioxide in the blood).
Most academic reports refer to the phenomenon as a type of ‘asphyxial game’ (with ‘the choking game’ or ‘the fainting game’ appearing to be the most commonly reported). Sometimes these ‘games’ are played alone and typically involve self-strangulation, and sometimes with others (where like my own experiences, the cutting off of the oxygen supply was carried out by somebody else. As with autoerotic asphyxiation, the aim of the game is to intentionally cut off the oxygen supply to the brain to experience a feeling of euphoria (the only difference being that in children’s games, it is not done for a sexual reason). A Wikipedia entry on the topic notes:
“According to Dr. Steve Field, chairman of the Royal College of General Practitioners in London, the fainting game is pursued primarily by children and teens ‘to get a high without taking drugs.’ Children ‘aren’t playing this game for sexual gratification.’ It is frequently confused with erotic asphyxiation, which is oxygen deprivation for sexual arousal. Unlike erotic asphyxiation, practice of the fainting game appears to be uncommon in adulthood”.
My own personal experiences of this would support Dr. Field’s assertions. There has been relatively little research into the practice although a fairly recent (2010) paper by Dr. Joseph Drake and colleagues in the journal Academic Pediatrics claims that ‘thrill-seeking’ is risk factor. Another paper published in a 2009 issue of the journal Injury Prevention (led by Dr. A.J. MacNab) said there was a perception among those who engaged in it that inducing fainting was a low-risk activity (something that I can attest to until I thought my friend had accidentally killed someone).
The paper led by MacNab attempted to determine the prevalence of knowledge about and participation in asphyxial games and how best to raise awareness of this risk-taking behaviour and provide preventive education. The study collected data from children and adolescents (aged 9-18 years with an average age of 13.7 years) at eight middle and high schools in Texas (n=6) and Ontario (n=2). They also noted that there had been a recent death from playing the choking game in one of the Texas schools, and that two other fatalities had occurred within the state. Over 2500 questionnaires were completed. They reported that 68% of children had heard about the game, 45% knew somebody who played it, and 6.6% had tried it (and 40% perceived no risk from the activity). The study found that the most respected source of a preventive education message was parents for pre-adolescents (43%) or victim/victim’s family (36%) for older adolescents.
In the 2008 book The Path to Addiction: And Other Troubles We Are Born To Know, Richard McKenzie Neal also says the author reasons that children participate in fainting games include curiosity (as to what the act of fainting might feel like), peer pressure (including a challenge or a dare or a rites of passage into a particular social group), exploration of ways to ‘get high’ and intoxicated at no financial cost. I also read that:
“[In] self-induced hypocapnia blackouts the victim may experience dreaming or hallucinations, though fleetingly, and regains consciousness with short-term memory loss and involuntary movement of their hands or feet. Full recovery is usually made within seconds but these activities cause many permanent brain injuries or death”
This description matches my own personal experiences of playing the fainting game and also seems to match our friend’s account that he thought he was a seal while unconscious. Like autoerotic asphyxiation, the playing of asphyxial games among children and teenagers has occasionally led to fatalities and reported in the clinical and medical literature. For instance, a recent case was reported by Dr. M.K. Egge and colleagues in the journal Pediatric Emergency Care. Their case was a 12-year-old girl who was brought to the paediatric emergency department after her mother found her hanging from her bunk bed. She died five days after being admitted to hospital and it was eventually found that she had played the choking game. Most cases of asphyxial game playing have been reported in the US, UK and Australia, although I did come across papers written in both Spanish and French about the phenomenon.
How prevalent the activity is debatable as most of the academically published studies are case reports (usually when a problem – and in some cases, death – has occurred). One 2006 US (Ohio-based Youth Health Risk Behavioral Survey) study (but not peer reviewed as far as I can tell) reported that approximately one in ten teenagers (11%) aged 12 to 18 years had engaged at least once in fainting games with the figure rising to almost one in five older teenagers (19%) among those aged 17 and 18 years. No-one knows how many teenagers have suffered brain damage or died as a result of such activities. One of the better published studies on fainting/choking games was published by Dr. R.L. Toblin and colleagues in the Journal of Safety Research who reported:
“Because no traditional public health dataset collects data on this practice, the [Centers for Disease Control and Prevention] used news media reports to estimate the incidence of deaths from the choking game. This report describes the results of that analysis, which identified 82 probable choking-game deaths among youths aged 6-19 years during 1995-2007. Seventy-one (86.6%) of the decedents were male, and the mean age was 13.3 years”.
The study also noted that deaths were recorded in 31 states and were not clustered by location, season or day of week. My brief examination of the literature suggests that a significant minority of adolescents have engaged in asphyxial game playing and that in extreme cases it may lead to death. It would certainly appear to be an activity that parents and teachers should be made more aware of.
- According to the online Urban Dictionary, asphyxial games have many different names worldwide including: Airplaning, America Dream Game, Black Boxing, Black Out Game, Breath Play, Breathing the Zoo, Bum Rushing, California Blackout, California Choke, California Dreaming, California Headrush, California High, California Knockout, Catching Some Zs, Choking Game, Cloud Nine, Crank, Dream Game, Dreaming Game, Dying game, Fall Out Game, Flat Liner, Flatline Game, Flatliner Game, Funky Chicken, Getting Passed Out, Grandma’s Boy, Groobling, Halloween, Harvey Wall Banger, High Riser, Hoola Hooping, Hyperventilation Game, Indian Headrush, Knockout Game, Passing Out Game, Pass-out Game, Purple Dragon, Natural High, Neckies, Redline, Rising Sun, Rocket Ride, Sandboxing, Sleeper Hold, Sleepers, Space Monkey, Speed Dreaming, Suffocation Game, Suffocation Roulette, The Game, The Mysto World, Tingling Game, Trip to Heaven
Barberia-Marcalain, E., Corrons-Perramon, J., Suelves, J.M., Alonso, S.C., Castella-Garcia, J. & Medallo-Muniz, J. (2010). [The choking game: a potentially lethal game]. Anales Pediatrica (Barcelona), 73, 264-267.
Centers for Disease Control and Prevention (2008). Unintentional strangulation deaths from the “choking game” among youths aged 6-19 years: United States, 1995-2007. Morbidity and Mortality Weekly Report, 57, 141-144.
Drake, J.A., Price, J.H., Kolm-Valdivia, N. & Wielinski, M. (2010). Association of adolescent choking game activity with selected risk behaviors. Academic Pediatrics, 10, 410-416.
Egge, M.K., Berkowitz, C.D., Toms, C. & Sathyavagiswaran, L. (2010). The choking game: A cause of unintentional strangulation. Pediatric Emergency Care, 26, 206-208.
MacNab, A.J., Deevska, M., Gagnon, F., Cannon, W.G. & Andrew, T (2009). Asphyxial games or “the choking game”: A potentially fatal risk behavior. Injury Prevention, 14, 45-49.
Neal, R.M. (2008). The Path To Addiction: And Other Troubles We Are Born To Know. Bloomington, Indiana: Author House.
Shlamovitz, G.Z., Assia, A., Ben-Sira, L. & Rachmel, A. (2003). “Suffocation roulette”: A case of recurrent syncope in an adolescent boy. Annals of Emergency Medicine, 41, 223-226.
Toblin, R.L., Paulozzi, L.J., Gilchrist, J. & Russell, P.J. (2008). Unintentional strangulation deaths from the “choking game” among youths aged 6-19 years -United States, 1995-2007. Journal of Safety Research, 39, 445-448.
Urkin, J. & Merrick, J. (2006). The choking game or suffocation roulette in adolescence (editorial). International Journal of Adolescent Medicine and Health, 18, 207-208.
Arguably one of the most extreme of human conditions is having congenital insensitivity to pain (CIP). One of the most high profile portrayals of CIP (which is where I first became aware of the condition) was in The Girl Who Played With Fire (the sequel of The Girl With The Dragon Tattoo), where one of the peripheral characters (Ronald Niedermann – ‘The Giant’) had CIP and was seen as physically invulnerable by those around him.
CIP was first reported by Dr. G. Dearborn in 1932 (in the Journal of Nervous and Mental Diseases) and is also known as congenital analgesia. Those with CIP have no capacity to feel physical pain, usually because of a hereditary genetic mutation associated with the body’s pain receptors. However, there are also cases where the causes are non-genetic. For instance, there are a few cases of CIP that appear to be due to an increase in endorphins (the body’s own morphine-like chemicals) in the brain.
Although CIP might sound like a great (almost superhuman) condition to have, individuals with CIP are much more susceptible to death via trauma as they are completely unaware of what damage has been done to their body following accidents (so they can’t feel cuts, know if they have bitten their tongue, or know if they have broken bones). Furthermore, one of the behaviours associated with CIP is self-mutilation (as highlighted in a 2010 case study of a young boy in the Online Journal of Health and Allied Sciences by Dr. Praveen Kumar and his colleagues). Evolutionary psychologists would therefore argue that pain perception is an evolutionary necessity to avoid injury and/or death.
The condition is very rare (for instance, in the US, it is estimated that only around 100 people have the condition). However, there is a higher incidence of the disorder in societies where there is less biodiversity (so-called ‘homogenous societies’). For instance, an interesting 2006 paper by Dr. Jan Minde in the journal Acta Orthopaedica Supplementum reported that in the village of Vittangi (in the north Swedish Municipality of Kiruna) had documented 43 cases. Given the hereditary nature of CIP, many papers tend to report case studies within families. For instance, Dr. D.C. Thrush reported across two papers in a 1973 issue of the journal Brain, the case of four siblings with CIP that all reported numerous painless injuries, bone fractures, and autonomic dysfunction. Similarly, Dr. Karmani and colleagues reported on a family where three out of four children all had CIP in the Journal of the Royal Society for Medicine in 2001. They reported that in relation to the condition:
“Presentation in childhood is commonly at the time of tooth eruption, with biting and self-mutilation of lips, tongue and digits. Pyrexia of unknown origin is another way the condition can show itself in early infancy. Cuts, abrasions and burns of the limbs are common”.
CIP is different from the group hereditary sensory and autonomic neuropathy (HSAN) disorders that inhibit specific sensations (which I’ll hopefully cover in a future blog). A 2002 paper in the Journal of Bone and Joint Surgery by Dr. E. Bar-On and colleagues reported that among those with CIP “musculoskeletal manifestations are very common although the pathology, inheritance, and pathophysiology of these, as well as their relationship to the different subtypes, have only been partially clarified, mainly in case reports”. Other than the incapacity to feel pain, those with CIP are physically normal (although some individuals have difficulty in experiencing different temperatures). The Wikipedia entry on CIP also notes that:
“Children with this condition often suffer oral cavity damage both in and around the oral cavity (such as having bitten off the tip of their tongue) or fractures to bones. Unnoticed infections and corneal damage due to foreign objects in the eye are also seen. Because the child cannot feel pain they may not respond to problems, thus being at a higher risk of more severe diseases or otherwise. In some people with this disorder, there may be a mild intellectual disability”.
Another minority may have CIP in the ‘voltage-gates sodium channel SCN9A’ (and in the words of Vienna by Ultravox, “this means nothing to me”). There is a series of papers published by Dr. James Cox and his colleagues in journals like Nature and Human Mutation examining the hard-core genetics of CIP. I had hoped that the Wikipedia entry on the genetics of CIP might dumb things down a little but after reading the following, I am still generally none-the-wiser:
“Patients with such mutations are congenitally insensitive to pain and lack other neuropathies. There are three mutations in SCN9A: W897X, located in the P-loop of domain 2; I767X, located in the S2 segment of domain 2; and S459X, located in the linker region between domains 1 and 2. This results in a truncated non-functional protein…it is expected that a loss of function mutation in SCN9A will lead to abolished nociceptive pain propagation”.
Some people working in the field distinguish between pain insensitivity and pain indifference. Pain insensitivity refers to individuals who have absolutely no perception of the stimulus to pain (i.e., they are unable to describe the type or intensity of pain). Pain indifference refers to individuals that have perception of the stimulus to pain have inappropriate responses to the pain stimulus (e.g., they wouldn’t flinch if something very hot or on fire touched their flesh).
Finally, Dr. Praveen Kumar and colleagues report in the Online Journal of Health and Allied Sciences that there is “no single gold standard treatment available” for CIP and that there are some studies suggesting (the opioid antagonists) naloxone and naltrexone (most often used in the treatment of drug addictions) can be used to reverse the analgesic effects of CIP. However, they also note that treatment with opioid antagonists “lacks evidence and further support” and that most treatments are concerned with other associated conditions.
Bar-On, E., Weigl, D., Parvari, R., Katz, K., Weitz, R. & Steinberg, T. (2002). Congenital insensitivity to pain. Journal of Bone and Joint Surgery, 84, 252-257.
Cox, J.J., Reimann, F. & Nicholas, A.K. (2006). An SCN9A channelopathy causes congenital inability to experience pain. Nature, 444, 894–8.
Cox, J.J., Sheynin, J., Shorer, Z., et al (2010). Congenital insensitivity to pain: Novel SCN9A missense and in-frame deletion mutations. Human Mutation, 31, E1670-E1686.
Dearborn, G. (1932). A case of congenital general pure analgesia. Journal of Nervous and Mental Diseases, 75, 612–615.
Karmani, S., Shedden, R. & De Sousa, C. Orthopaedic manifestations of congenital insensitivity to pain. Journal of the Royal Society of Medicine, 94, 139-140
Kumar, P.B, Sudhakar S. & Prabhat, M.P.V. (2010). Case report: Congenital insensitivity to pain. Online Journal of Health and Allied Sciences, 9(4).
Manfredi, M., Bini, G., Cruccu, G., Accornero, N., Berardelli, A. & Medolago, L. (1981). Congenital absence of pain”. Archives of Neurology, 38, 507-511.
Minde J (2006). Norrbottnian congenital insensitivity to pain. Supplementum 77, 2-32.
Nagasakoa, E.M., Oaklanderb, A.L., Dworkin, R.H. (2003). Congenital insensitivity to pain: an update. Pain, 101, 213–219.
Thrush, D.C. (1973). Congenital insensitivity to pain: A clinical, genetic and neurophysiological study of four children from the same family. Brain, 96, 369-86.
Thrush, D.C. (1973). Autonomic dysfunction in four patients with congenital insensitivity to pain. Brain, 96, 591-600.
Wikipedia (2012). Congenital insensitivity to pain. Located at: http://en.wikipedia.org/wiki/Congenital_insensitivity_to_pain