Category Archives: Obsessive-Compulsive Disorder
In a previous blog, I examined Body Dysmorphic Disorder (BDD). At its simplest level, BDD is a distressing, handicapping, and/or impairing preoccupation with an imagined or slight defect in body appearance that the sufferer perceives to be ugly, unattractive, and/or deformed. BDD sufferers can think about their perceived defect for hours and hours every day. The International Classification of Diseases (ICD-10) criteria for BDD is:
- Persistent belief in the presence of at least one serious physical illness underlying the presenting symptom(s), even though repeated investigations and examinations have identified no adequate physical explanation, or a persistent preoccupation with a presumed deformity or disfigurement.
- Persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or abnormality underlying the symptoms.
One particular body part that has been the focus of some research in the BDD field is that of genitalia. Many men worry about the size of their penis and think it is too small. This is perfectly normal and the worry or concern is highly unlikely to be a symptom of BDD. In a 2004 issue of the Postgraduate Medical Journal, British psychiatrist Dr David Veale reported that although there are broad similarities between the genders in BDD, there are some differences. For instance, men with BDD show a greater preoccupation with their genitals, and women with BDD are more likely to have a co-morbid eating disorder. Dr. David Sarwer (writing in a 2006 issue of Plastic and Reconstructive Surgery) asserted that the rate of body dysmorphic disorder should be examined among patients re-questing atypical procedures and cites the example of those individuals requesting genital surgery.
Back in 2008, Channel 4 in the UK had a television series called Penis Envy. The first episode (The Perfect Penis) featured a US psychology student who paid $4000 to have his penis lengthened by cutting the ligament in his pubis. Such actions might be indicative of BDD but the programme didn’t explore this facet. Following such operations, men then have to spend the following weeks suspending a weight from their penis for at least eight hours a day. For all the financial and physical burdens faced, the average increase in length is only 0.5-3cm (with official statistics being closer to 0.5cm than 3cm). Other methods of increasing genital size include the injection of silicon into the penis (although this is dangerous and can result in a silicon embolism).
Dr. Stephen Snyder (Associate Clinical Professor of Psychiatry, Mount Sinai School of Medicine, New York, US) was interviewed about (so-called) ‘Penile Dysmorphic Disorder’ (PDD) in an online Psychology Today article. He was quoted as saying:
“I don’t know of any statistics on [PDD]. Anxiety or insecurity about penis size is extremely common in men. It would be difficult to determine how frequently the more serious condition of penis-focused BDD occurs. People with BDD tend to avoid mental health specialists…It’s much more likely I think that a man with penile BDD will purchase penis enlargement equipment or consult a surgeon than consult someone like me…Some people seem to have an innate tendency for obsessive thinking. Why some of these people develop BDD, and others OCD or Anorexia Nervosa is unknown…A man who begins to obsess about the size of his penis may begin to compulsively and repeatedly measure his erections, and to avoid dating because he’s convinced he’ll be humiliated. Then the whole thing can spiral out of control, until ultimately he’s online studying penis enlargement techniques”.
A 2006 study led by Dr. J. Lever and published by Psychology of Men and Masculinity reported that in an online survey of over 52,000 participants, most male participants rated their penis as average (66%) and only 22% as large and 12% as small. Among the female participants, around 85% of women were satisfied with their partners’ penile size, while only 55% of men were satisfied, with 45% wanting to be larger (and 0.2% to be smaller).
Just recently, Dr. Warren Holman highlighted the case of ‘Sam’, a 17-year-old white male from a middle-class Jewish family living in Midwest USA with penile dysmorphic disorder (in a 2012 issue of Social Work in Mental Health). As Dr. Holman reported:
“Sam had stopped attending school several weeks earlier, and on many days would not even leave his home. He said he wanted to remain at home and away from school because, ‘My penis is shrinking and people can tell.’ Sam reported he had had his anxiety about his penis for about a year, but until recently had been able to reason himself out of it…Sam was well related, and his mental status was unremarkable except for his belief about his penis”.
Dr. Holman believed that Sam’s conviction that his penis was shrinking (and people could tell) suggested three possible diagnoses (i.e., social phobia; BDD and/or delusional disorder of the somatic type; or schizophrenia). Holman eventually reached the conclusion that Sam’s beliefs were due to BDD although did say that it “may be in a prodromal phase of schizophrenia”. Sam was treated via a form of psychodynamic counselling (which much to the disappointment of Holman ultimately failed perhaps because of initial misdiagnosis).
In 2007, British urologists Dr. Kevan Wylie and Dr. Ian Eardley published a review on penile size in BJU International. They summarized all of the studies on penile size that have examined flaccid penis length, stretched penis length, erect penis length, flaccid penis girth and erect penis girth. They reported that:
“Stretched penile length in these studies was typically 12–13 cm, with an erect length of 14–16 cm. For girth, there was again remarkable consistency of results, with a mean girth of 9–10 cm for the flaccid penis and 12–13 cm for the erect penis…Concern over the size of the penis, when such concern becomes excessive, might present as the ‘small penis syndrome’ [SPS], an obsessive rumination with compulsive checking rituals, body dysmorphic disorder, or as part of a psychosis”.
However, they did also assert that more research was required on the effects of race and age on penile length. Wylie and Eardley speculate that SPS (or ‘locker room syndrome’ as they also call it) originates in childhood following the sight of their father’s, elder sibling’s and/or older friend’s penis. This appears to have support from a 2005 study (also published in BJU International). Dr. N. Mondaini and Dr. P. Gontero surveyed men who thought they had a small penis at an andrology clinic and reported that nearly two-thirds said their SPS had begun in childhood (63%) with the rest saying it began in adolescence (37%).
Wylie and Eardley also examined the treatment options of men with SPS and also examined the evidence of commercial penis extending techniques. They concluded that:
“It is recommended that the initial approach to a man who has SPS is a thorough urological, psychosexual, psychological and psychiatric assessment that might involve more than one clinician…Conservative approaches to therapy, based on education and self-awareness, as well as short-term structured psychotherapy [cognitive-behavioural therapy] are often successful, and should be the initial interventions in all men. Of the physical treatments available, there is poorly documented evidence to support the use of penile extenders. More information is need on the outcomes with these devices. Similarly, there is emerging evidence about the place of surgery and there are now several reports suggesting that dividing the suspensory ligament can increase flaccid penile length”.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Goodman, M.P. (2009). Female Cosmetic Genital Surgery. Obstetrics and Gynecology, 113, 154-159.
Holman, W.D. (2012). “My Penis Is Shrinking and People Can Tell”: A Confusing Case of Apparent Body Dysmorphic Disorder. Social Work in Mental Health, 9, 319-335.
Morrison, T.G., Bearden, A., Ellis, S.R. & Harriman, R. (2005). Correlates of genital perceptions among Canadian post- secondary students. Electronic Journal of Human Sexuality, 8. Located at: http://www.ejhs.org/volume8/GenitalPerceptions.htm
Lever, J., Fredereicjk, D.A. & Peplau, L.A. (2006). Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men and Masculinity, 3,129-143.
Mondaini, N. & Gontero, P. (2005). Idiopathic short penis: myth or reality? BJU International, 95, 8–9.
Sarwer, D.B. (2006). Body Dysmorphic Disorder and cosmetic surgery. Plastic and Reconstructive Surgery, December, 168e-180e.
Snyder, S. (2011). When size obsession gets out of hand. Psychology Today, June 11. Located at: http://www.psychologytoday.com/blog/sexualitytoday/201106/when-size-obsession-gets-out-hand
Sondheimer, A. (1988). Clomipramine treatment of delusional disorder-somatic type. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 188-192.
Veale, D. (2004). Body dysmorphic disorder. Postgraduate Medical Journal, 80, 67-71.
Wylie, K.R. & Eardley, I. (2007). Penile size and the ‘small penis syndrome’. BJU International, 99, 1449–1455.
“Sixty-four million people do it at least once a week. Nabokov wrote about it. Bill Clinton even did it in the White House” (Marc Romano, 2005).
I’m sure many of you reading this opening quote will think that it refers to sexual infidelity but it doesn’t. I was also deliberately obtuse in the title of today’s blog to throw you off the scent of what today’s blog is about. Well, to put some of you out of your misery, the topic under the microscope today is crossword puzzles. For those who don’t know, a cruciverbalist is an enthusiast of word games (especially of crosswords). According to Michael Quinion in his excellent World Wide Words website:
“[The word ‘cruciverbalist’] seems to have appeared in English about 1980 (the first reference I can find is to the Compleat Cruciverbalist of 1981 by Stan Kurzban and Mel Rosen, subtitled ‘how to solve, compose and sell crossword puzzles for fun and profit’). However, Stan Kurzban tells me that Mel Rosen had encountered the word some years earlier in the title of a directory of crossword puzzle notables that was not widely circulated. Whatever its origin, cruciverbalist has spread into the wider language as a result of their efforts to the extent that it now appears in some larger recent US dictionaries. The word is a modern mock-Latin invention, being a translation back into Latin of the English crossword (using Latin crucis, cross, as in words like cruciform, plus verbum, word, as in verbose or verbatim).There is also cruciverbalism, for the art of crossword compilation or crossword fandom generally, but that is much rarer”.
The opening quote comes from Marc Romano’s 2005 book The Crossword Obsession: The History and Lore of the World’s Most Popular Pastime who asserted that: “the crossword puzzle has arguably been our national obsession since its birth almost a century ago”. Seeing the word ‘obsessive’ was enough to make me think it was a topic worthy of consideration of writing a blog about it (especially when reading the accompanying blurb for Romano’s book):
“Saying this is a book about puzzles is to tell only half the story. It is also an explanation into what crosswords tell us about ourselves – about the world we live in, the cultures that nurture us, and the different ways we think and learn. If you’re a puzzler, Crossworld will enthrall you. If you have no idea why your spouse send so much time filling letters into little white squares, Crossworld will tell you – and with luck, save your marriage”.
On a personal note, I ought to declare a vested self-interest in that I been doing cryptic crosswords since I was taught to do them by my father in my mid-teens. In the early 1990s until the late 1990s I did (or rather attempted) The Guardian’s cryptic crossword almost every day (the birth of my daughter put a stop to daily crosswords and what little spare time I had outside of my job). On the way to a conference in Bristol in 1998, I had a race on the train with one of my departmental colleagues (Bob Rotheram) as to who could complete that day’s Guardian crossword first. I even got a letter in The Guardian (November 26, 2002) about a crossword puzzle set by my favourite crossword setter (John Galbraith Graham, better known under his crossword compiling pseudonym ‘Araucaria’). Many of the clues in the prize crossword I had just completed related to an anagram of the word ‘presbyterians’. The letter I had published said:
“I don’t know what is worse. The fact that some clues in the prize crossword related to Britney Spears and her hit singles, or the sad fact that I knew the answers to them all!”
The fact that ‘presbyterians’ is an anagram of singer ‘Britney Spears’ I found amazing (although my favourite anagram in one of Araucaria’s crosswords was ‘synthetic cream’ being an anagram of the football team ‘Manchester City’). I am also a huge fan of crossword homophones (words that are pronounced the same but are completely different in definition and meaning) and on which most forms of punning are based. This includes many of my blog titles such as my articles on body dysmorphic disorder (‘Flaw management’), biting fetishes (‘Bit sighs’), pandrogyny (‘A gender setting’), and gambling spending (‘Stake and chips’), as well as my blogs on the psychology of revulsion (‘Disgust discussed’), Exploding Head Syndrome (‘A noise that annoys’) and Jerusalem Syndrome (‘Wholly holy’). I love crosswords so much that I even have an all-time favourite clue (“Late opening” [seven letters]; Answer: AUTOPSY). Total genius!
Doing crosswords appears to be a very popular hobby. According to Dean Olsher in his 2009 book, From Square One: A Meditation, with Digressions, on Crosswords, about 50 million American people do crosswords. Olsher says that for some, crosswords are a pastime and for others it is a form of escapism (suggesting that crosswords may produce psychological feelings and motivations associated with addictive behaviours). Olsher noted that some people like the film director Alfred Hitchcock “didn’t get” crosswords. Hitchcock told film actor, director and screenwriter Francois Truffaut that:
“I don’t really approve of whodunits because they’re rather like a jigsaw or crossword puzzle. No emotion. You simply wait to found out who committed the murder”
Olsher claims Hitchcock fell prey to a common false dichotomy that thinking and feeling are an either/or proposition. Olsher claims they are inextricable, and that cerebral and emotional satisfaction are not at odds with each other. For Olsher, crosswords can be an exhilarating experience and akin to seated meditation. However, he also notes that doing crosswords (based on his own personal experience) could be an addiction:
“It is more honest, though, to think of crosswords as a habit, like smoking. It’s just something to do, every day, because it’s there. When finished with a puzzle, I don’t pump my fists in triumph or congratulate myself for my perseverance. I solve crosswords because they bring on a feeling of emptiness, and paradoxically, that feeling seems to fill a hole deep inside. It’s not a release, it’s not a flushing out, although both those terms grasp at some aspect of it. Norman Mailer said that for him, solving the crossword every day was like combing his brain. This simile is strong because it has nothing to do with usual mental fitness. It’s not about intelligence or holding onto memory. Crosswords bring about a focused state of mind, the elusive ‘flow state’. Then there are days when I decide that this is all an elaborate self-deception. That the puzzle is indeed an escape mechanism. The crossword addiction is not a metaphor but a destructive literal truth”
I was surprised to find there has been quite a lot of academic research on the benefits of doing crosswords (although very little on whether doing crosswords can be obsessive and/or addictive). However, the psychologist Dr. Howard Rachlin does mention in a number of his writings on addiction that there are many activities that could be described as ‘positive addictions’ including “listening to classical music, collecting stamps, exercise, reading novels, doing crossword puzzles”. Dr. Rachlin also noted in a paper published in a 2002 issue of the journal Behavioral and Brain Sciences (BBS):
“Patterns of behavior may be maintained without extrinsic rewards. For example, on a relatively small scale, activities such as solving jigsaw or crossword puzzles are valuable in themselves. People, like me, who like to do crossword puzzles, find value in the whole act of doing the puzzle. When I sit down on a Sunday morning to do the puzzle I am not beginning a laborious act that will be rewarded only when it is completed. Yet, despite the lack of extrinsic and intrinsic reward for putting in that last particular letter, completing the puzzle is, for me, a necessary part of its value. Like listening to symphonies, the pattern is valuable only as a whole. Extrinsic rewards may initially put together the elements of these patterns but the patterns, once formed, are maintained by their intrinsic value. The cost of breaking the pattern is the loss of this value – even that of the parts already performed”.
However, Rachlin is not without his critics. In responses to the BBS paper, Dr. Stephen Kaplan and Dr. Raymond De Young claimed that Rachlin’s interpretation of intrinsic motivation as arising from a string of habits was far from convincing. More specifically, they noted that the “fascination with crossword and jigsaw puzzles seems far more likely to be an expression of the human inclination to solve problems, a tendency humans share with nonhuman primates”. Another response to the BBS paper by Dr. Thomas R. Zentall claimed that the concept of intrinsic reinforcement is needed to explain the variety of behaviour that has no extrinsic material or social reward, such as crossword puzzle solving. He argues that:
“Intrinsic reinforcers are difficult to assess. They are what [are] left once you have ruled out extrinsic reinforcers, and in the case of humans, typically we assess them by means of verbal behavior (e.g., ‘I just like doing it’). But this sort of definition can easily become circular, especially when we are talking about behavioral patterns that are themselves not clearly defined. One can hypothesize that extrinsic reinforcers become internalized, but that does not explain, it only describes”.
Doing crosswords may even be of psychological and practical benefit. For instance, Dr. Mike Murphy and Dr. Roisin Cunningham published a paper last year in the Irish Journal of Psychology claiming that: “a crossword a day improves verbal fluency”. More specifically they examined ‘semantic verbal fluency’ (SVF) an important contributor to general communication ability. In their study, 34 final year students completed a daily crossword for one month and compared this to a control group of 40 students who did not do any crosswords. Their results indicated that the crossword group experienced greater improvement in SVF than the control group. They concluded that doing simple crosswords may be a relatively straightforward way improving SVF among students who are about to enter the job market and need good transferable skills.
Dr. Graham Pluck and Dr. Helen Johnson writing in a 2011 issue of Education Science and Psychology claim that stimulating curiosity (with activities such as crosswords) can enhance learning. They drew on the work of Dr. Ludwig Lowenstein who noted that many features of human behaviour appear counter-productive on the surface but are not. For instance:
“Lowenstein discusses the interest that many people have in completing puzzles such as crosswords, or why soap operas end on cliff-hangers. According to the theory, the information gaps that people are exposed to act to motivate them to obtain the missing information, either by persevering to complete the puzzle or tuning in to watch the next episode of the soap opera”.
Another study led by Dr. Joshua Jackson and published in a 2012 issue of the journal Psychology and Aging claimed doing crosswords could change some aspects of personality among old-aged people. More specifically, they examined whether an intervention aimed to increase cognitive ability in older adults (i.e., doing crossword and Sudoko puzzles) affected the personality trait of openness to experience (i.e., being imaginative and intellectually oriented). In their study, old-aged adults completed a 4-month program in inductive reasoning training that included weekly crossword and Sudoku puzzles. They were then assessed continually over the following 30 weeks. Their findings showed that those who did crossword and Sudoko puzzles increased their openness scores compared to the control group. The authors claimed that this study is one of the very first to demonstrate that personality traits can change through non-psychopharmocological interventions.
Although there are a number of people online who have confessed as to being ‘crossword addicts’, (including the US rock singer and record producer Todd Rundgren in a June 2013 interview with Uncut magazine), I have yet to find any empirical evidence that it is negatively detrimental in people’s lives. For most, even those who describe themselves as ‘crossword obsessives’, it is a behaviour that adds to and enhances their lives.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Amende, C. (2001). The Crossword Obsession: The History and Lore of the World’s Most Popular Pastime. New York: Berkeley.
Davis, T.M., Shepherd, B. & Zwiefelhofer, T. (2009). Reviewing for exams: Do crossword puzzles help in the success of student learning? Journal of Effective Teaching, 9, 4-10.
Jackson, J.J., Hill, P.L., Payne, B.R., Roberts, B.W., & Stine-Morrow, E.A. L. (2012). Can an old dog learn (and want to experience) new tricks? Cognitive training increases openness to experience in older adults. Psychology and Aging, 27, 286-292.
Kaplan, S. & De Young, R. (2002). Toward a better understanding of prosocial behavior: The role of evolution and directed attention Behavioral and Brain Sciences, 25, 263-264.
Murphy, M. & Cunningham, R.K. (2102). A crossword a day improves verbal fluency: A report of an intervention study. Irish Journal of Psychology, 133, 193-198.
Olsher, D. (2009). From Square One: A Meditation, with Digressions, on Crosswords. New York: Simon & Schuster.
Pluck, G. & Johnson, H. (2011). Stimulating curiosity to enhance learning. Education Science and Psychology, 2(19), 24-31.
Rachlin, H. (2002). Altruism and selfishness. Behavioral and Brain Sciences, 25, 239-250.
Rachlin, H. (2003). Economic concepts in the behavioural study of addiction. In R.E. Vuchinich & N. Heather (Eds.), Choice, Behavioural Economics and Addiction. (pp.129-149). Oxford, UK: Pergamon Press.
Romano, M. (2005). Crossworld: One Man’s Journey into America’s Crossword Obsession. Blackpool: Broadway.
Underwood, G., Deihim, C. & Batt, V. (1994). Expert performance in solving word puzzles: From retrieval cues to crossword clues. Applied Cognitive Psychology, 8, 531-548.
Zentall, T.R. (2002). A potentially testable mechanism to account for altruistic behavior Behavioral and Brain Sciences, 25, 282.
It was only a few months ago that I watched the 2006 film Bug for the very first time. Directed by William Friedkin, it tells the story of a mentally ill drifter called Peter Evans (with a great performance by Michael Shannon). Evans ends up having a sexual relationship with Agnes White, a bisexual alcoholic junkie (played surprisingly well by Ashley Judd). During the film, Peter confides in Agnes his belief that he has a colony of microscopic bugs infested one of his molar teeth (and then in one ‘memorable’ scene starts pulling his own teeth out). Evans’ paranoia becomes increasingly erratic and becomes a shared belief with White (who also comes to believe that they are both infested with microscopic bugs; this sharing of a delusional belief is known as a ‘folie à deux’ [French for ‘a madness shared by two people’, a shared psychosis] and would make a good blog topic). However, today’s blog focuses on imagined bug infestation (i.e., delusional parasitosis) that is known in psychological and psychiatric terms as Ekbom’s syndrome (named after the Swedish neurologist Karl Ekbom who first described the condition in a number of published papers in the late 1930s).
As you have probably gathered from my quick film synopsis above, Ekbom’s syndrome (ES) is a type of psychosis in which sufferers have a vehement delusional belief that they are infested with parasites that those affected describe as bugs or insects crawling around under their skin (when in reality they simply do not exist). I ought to add that the characters in Bug also appeared to be suffering from ‘delusory cleptoparasitosis’ (DC) another type of insect psychosis in which the sufferer thinks the place where they live is infested with parasites (rather than from within their body). As a consequence, both ES and DC sufferers are more likely to seek the help of skin specialists (e.g., dermatologists) and insect specialists (e.g., pest control, entomologists) than psychologists.
In essence, ES is a tactile hallucination and is also known as ‘formication’ (which is the word that describes the feeling of insects crawling and/or burrowing underneath the skin’s surface. Formication is also one form of parasthaesia (of which other examples include the ‘pins and needles’ tingling sensations that many people experience regularly). Parasthaesia includes any non-permanent skin sensation including tickling, pricking, tingling, numbness, and/or burning. ES sufferers will focus on any unusual body mark on their skin as ‘evidence’ that they have a parasitic infection. It is not uncommon for obsessive and/or compulsive checking of the body to occur. The prevalence of ES is unknown although Dr. J. Koo and Dr. C. Gambla reported in the journal Dermatologic Clinic that they see around 20 new cases per year in the large US referral clinic.
In some psychological circles, ES has been used synonymously with Wittmaack-Ekbom syndrome that is more associated with ‘restless leg syndrome’ (RLS; something that I myself have suffered from due to a chronic spinal condition that I have). When I get my bouts of RLS, it really does feel as though I have tiny insects moving about inside my right leg. The difference between ES and RLS is that RLS is a real physical condition that has bona fide physical basis whereas the basis for ES is an imaginary delusion. Clinical and medical research has shown that ES is associated with a number of comorbid conditions including affective psychosis, paranoid schizophrenia, organic brain disease, neurosis, and anankastic/paranoid personality disorder. It has also been reported in some people undergoing alcohol withdrawal, cocaine misuse, cerebrovascular disease, senile dementia, and thalamic brain lesions.
There can also be medical complications for ES sufferers. The fictional example of someone pulling their teeth out is not unknown although the gouging or digging out of the perceived parasites is more common. However, a paper by Dr. M. Nel and colleagues in the Journal of the South African Veterinary Association, most ES sufferers are able to function normally in all other aspects of their lives, in spite of their fixed parasitic delusions. They also noted that:
“The typical history often describes numerous attempts at eradicating the infestation. These could include taking medication, applying topical treatments, using pesticides, making use of exterminators, discarding clothing and possessions and even relocating…In a study of 94 patients (Ohtaki, 1991), most patients complained of itching and/or a tickling sensation. In order to rid themselves of the so-called parasites, patients often scratch, pick and wash frequently or use caustic agents on their skin, almost invariably leading to traumatic skin lesions”.
According to one meta-analytic study of 1,223 ES cases (published by Dr. W. Trabart in the journal Psychopathology), the occurrence of ES as a shared psychotic disorder is an uncommon phenomenon. He reported only about 5-15% of such cases were found. It was also reported that ES was more common amongst females (two-thirds female, one-third male), and is more prevalent in those over the age of 40 years. The symptoms had lasted three to four-and-a-half years. ES can be classified into three sub-types (primary; secondary-functional; and secondary-organic) based on the presenting symptoms:
- Primary ES refers to individuals that have the delusional parasitic infestation but no other comorbid conditions (i.e., other mental functioning is normal). Those where ES occurs by suggestion from another individual (e.g., the folie a deux case mentioned above) would be included in this ES sub-type. (It’s also worth noting that at least three studies have reported either the folie à deux or folie à trois among family members or loved ones including papers in the British Journal of Psychiatry and Dermatologica). Treatment is usually pharmacotherapy-based and utilizes drugs that are used in the treatment of other delusional-based syndromes (e.g., atypical antipsychotic drugs such as risperidone and olanzapine.
- Secondary-functional ES refers to individuals that have the delusional parasitic infestation and are associated with another psychiatric condition (e.g., clinical depression, schizophrenia).
- Secondary-organic ES refers to individuals that have the delusional parasitic infestation that is caused by another medical illness (e.g., cancer, diabetes, tubercolosis, hyperthyroidism, vitamin deficiency, cerebrovascular disease, neurological disorders). Other conditions can also facilitate ES including drug abuse (including stimulant psychosis), various allergies, and the menopause). Treating the primary disorder will often lead to a reduction or elimination of the ES symptoms.
The most recent review of the literature I came across was by Dr. Andrea Boggild and colleagues, and published in a 2010 issue of the International Journal of Infectious Diseases, they concluded that:
“In summary, [delusional parasitosis] is one of the more challenging entities that infectious diseases specialists will be enlisted to help treat. Unfortunately, optimal therapeutic regimens leading to sustained remission are lacking, and assurances on the part of the clinician do little to ameliorate patient suffering”.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Berrios GE (1985). Delusional parasitosis and physical disease. Comprehensive Psychiatry 26, 395-403.
Boggild, A.K., Nicks, B.A., Yen, L., Voorhis, W.V., McMullen, R., Buckner, F.S., & Liles, W.C. (2010). Delusional parasitosis: six-year experience with 23 consecutive cases at an academic medical center. International Journal of Infectious Diseases, 14, e317–e321.
Bourgeois, M.L., Duhamel, P. & Verdoux, H. (1992). Delusional parasitosis: Folie à deux and attempted murder of a family doctor. British Journal of Psychiatry, 161, 709-711.
Frances, A. & Munro, A. (1989). Treating a woman who believes she has bugs under her skin. Hospital and Community Psychiatry, 40, 1113–1114.
Freinhar, Jack P (1984). Delusions of parasitosis. Psychosomatics, 25, 47-53.
Gieler, U. & Knoll, M. (1990). Delusional parasitosis as ‘folie à trois’. Dermatologica, 181, 122-125.
Goddard J (1995). Analysis of 11 cases of delusions of parasitosis reported to the Mississippi Department of Health. Southern Medical Journal 88, 837-839.
Gould, W.M. & Gragg, T.M. (1976). Delusions of parasitosis. Archives of Dermatology 112, 1745–1748.
Grace, K.J. (1987). Delusory cleptoparasitosis: Delusions of arthropod infestation in the home. Pan-Pacific Entomologist, 63, 1-4.
Koblenzer, C.S. (1993). The clinical presentation, diagnosis and treatment of delusions of parasitosi: A dermatologic perspective. Bulletin of the Society of Vector Ecologists 18, 6-10.
Koo, J. & Gambla, C (1996). Delusions of parasitosis and other forms of monosymptomatic hypochondriacal psychosis. General discussion and case illustrations. Dermatologic Clinic, 14, 429-438.
Morris, M. (1991). Delusional manifestation. British Journal of Psychiatry, 159, 83-87.
Hinkle, N.C. (2000). Delusory parasitosis. American Entomologist 46, 17-25.
Ohtaki, N. (1991). Ninety four cases with delusions of parasitosis. Japanese Journal of Dermatology, 101, 439-446.
Rasmussen, J.E. & Voorhees, J.J. (1990). Psychosomatic dermatology. Archives of Dermatology, 126, 90-93.
Nel, M., Schoeman, J.P. & Lobetti, R.G. (2001). Delusions of parasitosis in clients presenting pets for veterinary care. Journal of the South African Veterinary Association, 72, 167-169.
Trabert, W. (1995). 100 years of delusional parasitosis. Meta-analysis of 1,223 case reports. Psychopathology, 28, 238-46
Webb, J.P. (1993). Case histories of individuals with delusions of parasitosis in southern California and a proposed protocol for initiating effective medical assistance. Bulletin of the Society of Vector Ecologists 18, 16-24.
“When I got to pre-school, I discovered that thumb sucking was not the social norm. Other kids teased me: ‘Only babies suck their thumbs!’ This was terrible news. I didn’t want to be a baby, but there was no way for me to stop doing the only thing in the world that soothed me; the one thing I could do, in a violent home, to comfort myself and feel safe. So I compromised: I stopped sucking my thumb in public…But at home, or during any moment of privacy…my left thumb went automatically into my mouth. Rather than tapering off as I aged, my thumb sucking intensified, and I added a small swatch of cotton blanket to the ritual, rubbing it against my upper lip until it was soft and grey. My parents had split up, and I was moving from place to place with my mother and stepfamily, so nobody really had the energy to monitor my behavior. If anybody did notice and say something to me (‘Stop that, you’re going to ruin your teeth!’), I just popped the thumb out and waited 30 seconds before the coast was clear again” (Janice Erlbaum)
The opening quote is taken from Janice Erlbaum’s blog article “I was an adult thumbsucker” (a habit she managed to kick when she was 26 years old). From Erlbaum’s full account, I wouldn’t class the behaviour as an addiction although depending on what definition of addiction is used, an argument could perhaps be made. I have to admit that adult thumb sucking is something which I have often thought about as someone I know well has sucked her right thumb all her life. She’s now in her early forties and has two completely different shaped thumbs (one ‘normal’ and the other flat and very elongated) as a result of four decades of constant thumb sucking. She also tells me that her upper mouth palate has also changed shape and her thumb fits perfectly into the upper groove in her mouth. She also has a number of little routines she performs while sucking her thumb including the caressing of her eyelashes with her right index finger which when thumb-sucking is close to her eyes. She only ever does it when relaxing (such as when she’s watching television) and has learned not to do it in public. During her junior years and early adolescence, her parents tried to get her to stop, and at one point she was given a substance to coat her thumb in (which tasted disgusting when she put her thumb in her mouth). It didn’t work. She still sucked her thumb and put up with the horrible taste.
Most parents reading this will be aware that thumb-sucking tends to emerge in infancy (although there is some evidence that babies can suck their thumbs inside the womb. For instance, Professor Peter Hepper and his colleagues [Queen’s University, Belfast, Northern Ireland) have followed up children who were known to have sucked their thumbs as fetuses). Constant thumb-sucking is not necessarily problematic but depending on how the thumb is sucked, it can cause protruding teeth and other dental problems such as anterior open bite, malocclusion (i.e., misalignment of teeth or incorrect relation between the teeth of the two dental arches), and mucosal trauma. Other problems include deformity of the thumb (something which I have seen for myself first-hand) and speech problems. Thumb-suckers are also more prone to infections such as impetigo around the mouth (i.e., a highly contagious bacterial infection of the surface layers of the skin, which causes sores and blisters), and paronychia of the thumb (i.e., a skin infection that occurs around the nails). Basically, as children get older, the more of a problem thumb sucking is from a medical perspective. As one review of thumb sucking in the American Family Physician journal concluded:
“Major complications of thumb sucking, usually corrects spontaneously if thumb sucking ceases by six years of age. Thumb sucking in a child less than two years of age requires no treatment. In a three- to four-year-old child, thumb sucking may be secondary to changes in the child’s emotional environment, and treatment should be directed at correcting the underlying problem. Thumb sucking that persists beyond the age of six years should be treated”.
An article on thumb-sucking in Psychology Today by psychologist Dr. Susan Heitler looked at the topic of thumb-sucking. Dr. Heitler had been a thumb-sucker herself until she was nine-years old and had to endure “years of orthodonture” because of her childhood thumb-sucking. Her own daughter was also a thumb-sucker and her dentist told her that “trying to end thumbsucking will do more harm than good”, advice that she was not happy with given her own experiences. In her article, she wrote:
“Looks are hugely important to one’s success in life. Allowing thumbsucking to damage facial appearance is wrong advice. By the time a child is four or five, with the habit no longer socially appropriate and permanent teeth coming shortly, the risks of continuing to thumb or finger suck clearly outweigh the benefits…When does a bad habit qualify as an addiction? Usually it’s a function of how much the habit has become physiologically essential so that people feel craving when it is missing. That definitely happens with thumbsucking”.
Dr. Heitler’s article referred to empirical research that had been carried out on thumb-sucking although none of the main findings had any detail as to who had carried out the work, where the research was published, or what methodologies were employed (apart from very general information). Here are some of the main things she reported:
“In a study with premature infants, researchers found that infants who sucked their thumbs or a pacifier had shorter hospital stays. That was because rhythmic sucking soothed them so that they spent less energy in crying. In addition, sucking re-optimized their heart beats and breathing patterns if they were beginning to get upset…In studies of children who do or do not suck a thumb, finger or pacifier, it turns out that the suckers become emotionally more independent at a younger age. Researchers put a child and mom on one end of a long room. On the far end were appealing toys. The suckers ventured further and played with the toys away from Mom longer than the non-suckers…They just had higher self-confidence in being able to handle independent play, knowing that if they felt stressed they could suck for a bit, feel better, and resume playing on their own. It’s generally not until they become toddlers that the downsides of thumbsucking begin to outweigh the gains. Kids then tend to suck when they are trying to fall asleep, when they bored, when they are idling between activities, or to self-soothe when they are upset”.
One online article on thumb-sucking reports that it is a common activity among infants (30%-40% of those yet to start school) and around 10%-20% of children aged over six years. In a more academic source, Dr. Sherry Ellington and colleagues (in a 2000 issue of the Journal of Applied Behavior Analysis reported that thumb sucking is estimated to occur in 23% to 46% of children aged 1 to 4 years. As with the article by Dr. Heitler, it claims that thumb-sucking may have a psychological benefit for young children as it “allows them to consolidate emotions and handle their stresses”.
In a 1953 paper in the International Journal of Psychoanalysis, the Dr. Donald Winnicot presented his theory of transitional objects and phenomena. Dr. Winnicott compared thumb sucking with the use of external objects such as children’s use of comfort blankets drawing parallels between the two. He also a claims that childish actions like thumb sucking and objects like cuddly toys are the source of manifold adult behavior, amongst many others sexual fetishism. It is also claimed (particularly by psychodynamic psychologists) that such actions stem back to childhood trauma and that behaviours like thumb-sucking help facilitate the need to feel comforted and secure. Another early longitudinal study by Dr. Marjorie Honzik and Dr. John McKee published in the Journal of Pediatrics reported that after the first year of being born, girls more likely to suck their thumbs than boys. The main reason was speculated that “girls’ greater orality may involve greater pleasure from tactile stimulation”.
There doesn’t appear to be much empirical research on adult thumb sucking. A small 1996 study in the Journal of Clinical Psychiatry led by Dr. F. Castellanous found that in 12 intellectually normal adults with stereotypic movement disorder, eight of them displayed thumb-sucking and/or rocking behaviour (and 11 of them had an affective anxiety disorder suggesting that behaviours such as thumb-sucking may be engaged in to help reduce anxiety). A 2008 literature review by Dr Orlando Tanaka and colleagues in the American Journal of Orthodontics and Dentofacial Orthopedics reported some evidence that thumb-sucking might turn into nail biting. This might explain why there is such a seemingly low prevalence of thumb-sucking in adults. All the evidence suggests that thumb sucking in adults is not an addiction but in some people may be symptomatic of other underlying disorders.
Articles 2day (2012). Tic disorder and thumb sucking. July 2012. Located at: http://www.articles2day.org/2012/07/tic-disorder-and-thumb-sucking-other.html
Batista, E. (2012). Adult thumb sucking, January 12. Located at: http://www.edbatista.com/2012/01/adult-thumb-sucking.html
Castellanous, F.X., Ritchie, G.F., Marsh, W.L. & Rapoport, J.L. (1996). DSM-IV stereotypic movement disorder: persistence of stereotypies of infancy in intellectually normal adolescents and adults. Journal of Clinical Psychiatry, 57, 116-122.
Ellington, S.A., Miltenberger, R.G., Stricker, J.M., Garlinghouse, M.A., Roberts, J. & Galensky, T.I. (2000). Analysis and treatment of finger sucking. Journal of Applied Behavioral Analysis, 33, 41-52.
Erlbaum, J. (2012). It happened to me: I was an adult thumb sucker. August 2. Located at: http://www.xojane.com/it-happened-to-me/it-happened-me-i-was-adult-thumbsucker
Friman, P. C. (1987). Thumb sucking in childhood. Feelings and Their Medical Significance, 29, 11-14.
Heitler, S. (2012). Lessons from thumbsucking, the earliest addiction. Psychology Today, January 26. Located at: http://www.psychologytoday.com/blog/resolution-not-conflict/201201/lessons-thumbsucking-the-earliest-addiction
Hepper, P., Wells, D.L. & Lynch, C. (2004). Prenatal thumbsucking is related to postnatal handedness. Neuropsychologia, 43, 313-315.
Honzik, M.P. & John P. McKee, J.P. (1960). The sex difference in thumb-sucking. Journal of Pediatrics, 61, 726-732.
Leung, A.K. & Robson, W.L. (1991). Thumb sucking. American Family Physician, 44, 1724-1728.
Luke, L. S., & Howard, L. (1983). The effects of thumb sucking on orofacial structures and speech: A review. The Compendium of Continuing Education, 4, 575–579.
Tanaka, O.M., Vitral, R.W.F., Tanaka, G.Y., Pulido A. & Guerrero, & Camargoe, E.S. (2008). Nailbiting, or onychophagia: A special habit. American Journal of Orthodontics and Dentofacial Orthopedics, 134, 305-308.
Winnicott, D. (1953) Transitional objects and transitional phenomena. International Journal of Psychoanalysis, 34, 89-97.
I have to say that I have no idea what it must be like to lose an eye (i.e., enucleation) but one thing I can’t possibly begin to imagine is what it must like is to remove my own eye (i.e., auto-enucleation). However, there are many clinical and medical reports of people that self-mutilate by stabbing or removing their eye(s). Arguably the most infamous auto-enucleator was Oedipus (in Sophocles’ play) who removed both his eyes after he realized he had unwittingly slept with his own mother and killed his own father.
The psychiatrist Dr. Armando Favazza defines self-mutilation as “the deliberate, direct, non-suicidal destruction or alteration of one’s body tissue”. Dr. Niraj Ahuja and Dr. Adrian Lloyd writing in the Australian and New Zealand Journal of Psychiatry also add that self-mutilation relates to bodily self-damage without wishing to die. Dr. Favazza also believes there are three fundamentally different types of self-mutilation. Enucleation is included in the first type (major self-mutilation) and is the least common. Other forms of self-mutilation in this category include self-castration, penectomy (cutting off one’s own penis) and self-limb amputation.
The second type includes “monotonously repetitive and sometimes rhythmic acts such as head-banging, hitting, and self-biting” (which according to Dr Favazza occur mostly in “moderate to severely mentally retarded persons as well as in cases of autism and Tourette’s syndrome”). The final and most common forms of bodily self-mutilation are moderately superficial and include a compulsive sub-type (e.g., hair-pulling, skin scratching and nail-biting), as well as an episodic/repetitive sub-type (e.g., skin-cutting, skin carving, burning, needle sticking, bone breaking, and wound picking). Many of these self-harming behaviours are a symptom and/or an associated feature in a number of mental personality disorders (e.g., anti-social, borderline, and histrionic personality disorders).
Reports of auto-enucleation in the medical literature were first described in the 1840s. By the early 1900s, the act of removing one’s own eye was actually termed ‘Oedipism’ by Blonel. Auto-enucleation is (of course) exceedingly rare although a couple of studies in the American Journal of Ophthalmology (in 1984) and an analysis of 1,146 enucleations between 1980 and 1990 in the British Journal of Ophthalmology (in 1994) estimated there were 2.8 to 4.3 per 100,000 in the population. However, some papers (such as those by Dr. Favazza) on major self-mutilation have put the incidence as low as one in 4 million.
Enucleators are also known to be at increased risk of further self-harming, and (predictably) are more likely to be living in psychiatric institutions when the auto-enucleation event occurs. They are also at increased risk of removing the second eye at a later date if they didn’t pull out both eyes to start with. A review by Dr. H.R. Krauss and colleagues in a 1984 issue of the Survey of Opthalmology examined 50 cases of self-enucleation and reported that 19 of them had bilateral auto-enucleation (i.e., had removed both of their eyes). A 2007 paper by Dr. Alireza Ghaffari-Nejad and colleagues in the Archives of Iranian Medicine examined the many theories behind self-harming behaviour. They briefly overviewed theories ranging from Fruedian psychoanalytic theory to biologically-based theories. They wrote:
Psychoanalytically self-injurious behaviour has been linked to castration and explained as a process of failure to resolve oedipal complex, repressed impulses, self punishment, focal suicide and aggression turned inwards especially in cases of depression. [Other authors] have postulated interpersonal loss preceding self-injurious behaviour and linked it to rejection sensitivity…Biologically serotonergic depletion preceding self-mutilation has been linked to aggression and depression…Some authors have claimed strong moral, religious and delusional component”
A recent literature review by Dr. Alexander Fan in the journal Psychiatry reported that the vast majority of auto-enucleation cases suffer from psychotic illness (particularly schizophrenia) although other medical and/or psychiatric conditions associated with auto-enucleation include obsessive-compulsive neuroses, severe depression, post-traumatic stress disorders, drug-induced psychoses, bipolar mania. There are also case studies where auto-enucleation has been linked with structural brain lesions, Down Syndrome, epilepsy, neurosyphilis, and Lesch-Nyhan syndrome (juvenile gout). These are similar to other forms of extreme self-mutilation. For instance, self-mutilation in schizophrenia in response to auditory hallucinations has often been described as Van Gogh Syndrome (in reference to the painter’s self-excision of his own left ear)
Other reviews of the psychiatric literature have reported that those who remove their own eyes commonly have delusions (typically sexual and/or religious) and that when asked about motivations for self-harming include reasons such as guilt, atonement, sin, evil, etc. Although some authors have noted that enucleators with religious beliefs are often Christian, other case studies have made reference to other religious faiths (e.g., Muslims). Finally, another paper by Favazza in Hospital and Community Psychiatry concluded that:
“Males in a first episode of a schizophrenic illness that is characterized by delusions associated with a body part or religious delusions are at the greatest risk for MSM [major self-mutilation]. However, MSM of this severity is so rare that it cannot be predicted accurately unless there has been a previous attempt at self-injury or the patient has spoken about wanting to remove or injure an organ. Threatened ocular mutilation deserves special mention because it may occur in a hospital setting, and the case histories suggest that one-to-one nursing is not always be sufficient to prevent enucleation”.
Berguaa, A., Sperling, W. & Kuchlea M. (2002). Self-enucleation in drug-related psychosis. Ophthalmologica, 216, 269-271.
Eric, J.C., Nevitt, M.P., Hodge, D. & Ballard, D.J. (1984). Incidence of enucleation in a defined population. American Journal of Ophthalmology, 113, 138-44.
Fan, A.H. (2007). Autoenucleation: A case report and literature review. Psychiatry, October, 60-62.
Favazza, Armando (1998) ‘Introduction’, in Marilee Strong A Bright Red Scream: Self-mutilation and the Language of Pain. New York: Viking.
Favazza, A. & Rosenthal R. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44, 134-140.
Field, H. & Waldfogel, S. (1995). Severe ocular self-injury. General Hospital Psychiatry, 17, 224-227.
Gamulescu, M.A., Serguhn, S., Aigner, J.M., Lohmann, C.P., & Roider J. (2001). Enucleation as a form of self-aggression, two case reports and review of the literature. Klin Monatsbl Augenheilkd, 218, 451-454.
Ghaffari-Nejad, A., Kerdegari, M., & Reihani-Kermani, H. (2007) Self-mutilation of the nose in a schizophrenic patient with Cotard Syndrome. Archives of Iranian Medicine, 10, 540-542.
Gottrau, P., Holbach, L.M. & Nauman, G.O. (1994). Clinicopathological review of 1,146 enucleations (1980-90). British Journal of Ophthalmology, 78, 260-5.
Jeffreys, S. (2000). ‘Body art’ and social status: Cutting, tattooing and piercing from a feminist perspective Feminism and Psychology, 10, 409-429.
Krauss, H., Yee, R. & Foos, R. (1994). Autoenucleation. Survey of Ophthalmology, 29, 179-87.
MacLean, C. & Robertson, B.M. (1976). Self enucleation and psychosis. Archives of General Psychiatry, 33, 242-249.
Patil, B. & James, N. (2004). Bilateral self-enucleation of eyes. Eye, 18, 431-432.
Patton N. (2004). Self-inflicted eye injuries: A review. Eye, 18, 867-872.
Rao, K.N. & Begum, S. (1996) Self enucleation in depression; A case report. Indian Journal of Psychiatry, 38, 267-70
Witherspoon, D., Feist, F., Morris, R. & Feist, R. (1989). Ocular self-mutilation. Annals of Ophthalmology, 21, 255-259.
Back in 1991 while I was holidaying in Goa (India), I was lying on the beach with my (then) girlfriend (next to a dead dolphin, but that’s another story) when suddenly I felt something being stuck into my ears. It was a Goan man making a living out of removing earwax from the tourists with a specially designed earpick. At the time, I didn’t think much of it and all I can recall was speaking to one of the staff at the hotel reception about it. She said to me that for some people in the locality, earwax was “almost an obsession”.
Recently, I was re-reminded of this incident when I came across an article on Danny Brown’s webpage called ‘The completely pointless Google experiment’. Brown’s pointless experiment was to find ridiculous and obscure facts by typing various phrases into Google to discover what came back as the number 1 result. One of the phrases he typed in was “What is the weirdest earwax story ever?” He wrote that:
“Now I’m not one of these people that have a fetish for ear wax (and yes, they DO exist!) but this seemed like a rather innocuous question. According to the #1 result on Google, it’s using ear wax as a remedy for cold sores, as found on the Remedicated website, under ’15 of the weirdest home remedies as folk treatments ever’”
I wasn’t interested in the top-rated story (although I did read the Wikipedia entry on earwax and discovered that “many types of whales have a build-up of earwax which increases with time; the size of the deposit is sometimes the only way to determine the age of whales that do not have teeth”). What garnered my interest was Brown’s assertion that earwax fetishes “DO exist” (his emphasis, not mine). My first online search led to websites talking about mimikaki. The term ‘mimikaki’ is a Japanese word and describes the act of picking earwax out of the ears. I also read that the removal of earwax is often done in the context of lover’s grooming customs and rituals with one website claiming that “as with practically every aspect of Japanese culture, mimikaki is often fetishized”. The same website claimed that mimikaki services can be bought in a variety of Japanese establishments that offer massage and other grooming services. Someone else writing on the same website also noted:
“Ear picks are a commonly used item and preferred for earwax removal in East Asia. The person having their ears cleaned would lie down with their head in the lap of the person doing the cleaning. It is generally considered a pleasant feeling, like having one’s back scratched. The cleaning of ears is thus considered an act of intimacy, often performed by a mother to a child or, among adults, by one’s lover. It may also be performed alone or by professional (non-medical) ear cleaners on the streets of cities in countries such as China, India, Japan, Vietnam, and other Asian countries”
Having read this, I decided to see what it out there on earwax obsessions and fetishes. Academically, I found nothing (at least in relation to sexual fetishes). In the online world I came across various snippets relating to sexual earwax fetishes. An article about “five freaky fetishes” on the Daily Radar website included a paragraph on earwax fetishes and noted:
“Earwax. We’ve all heard of shit, piss, puke and so on fetishes. Frankly, I find them a little boring. Been there, done that…But I know there’s a big market out there for bodily fluids, so I came up with one you’ve likely not heard of before: earwax. It tastes like ambrosia if it was all waxy and it fits into many crevices of the body…It’s like naturally occurring honey is what it’s like! I don’t know why other bodily fluid fetishes have been popular enough to inspire Internet ‘memes’ while this earwax thing has yet to gain traction”
A 2010 news item in The Sportsman’s Daily claimed that Bill Belichick, head coach of the American football team New England Patriots had an ear/wax fetish. He was reported to have said: “I’m into Q-Tips. Any kind of swab basically. I enjoy sniffing ear wax. The hard of hearing really get my juices flowing. And I’ve got a headphone collection that would make the folks at Sony sit up and take notice”. In the same story, a sex therapist Dr. Clifton Hamels claimed that ear fetishes are among the rarest of fetishes. More specifically he said: “I’ve only had one patient that was into aural. But perhaps now that a high profile coach has let it all be heard, so to speak, other people will come forward and tell the world how they’re into ear”.
I managed to locate a few individuals on various online forums who claimed to have an earwax fetish. Most (but not all) of these were sexually based. Here are some examples
- Extract 1: “I have a huge earwax fetish…Sometimes I like to have fantasies of swimming in men’s earwax. It makes me super horny and I can get orgasms by just thinking of it…I also have a fantasy where I find this giant guy and I have him shove me in his ear and use me as a Q-tip. Does anyone else have these types of fantasies or is it just me?”
- Extract 2: “My fetish is horrible but I love it. have this earwax fetish. I sometimes daydream about swimming in a guy’s ears and drink the wax out of his ears. It makes me horny as hell. I sometimes imagine a guy pouring wax out of his ears and I start drinking and bathing the wax. I also do this as I’m masturbating and I get orgasms. I think of a lot of things about earwax to get horny. I hope I’m not alone because it is great and fills me with orgasmic energy. Sometimes I go without a month without cleaning my ears and sit on the toilet and pick my ears and eat it while masturbating and imagine its’ a guys ear wax”
- Extract 3: “Which of you ladies gets turned on by a man with lots of hot, yellow goop in his ears? I tend to have a lot of wax in my ears when I wake up and wonder if any pretty mommas around here find that sexy? Do you fantasize looking into my ear seeing something that looks like an apple pie cooking in an oven and just want to shove your tongue in there and dig out all that steamy slop. Sometimes I have so much it falls out and looks like pieces of buttered popcorn laying on my pillow”
- Extract 4: “As it turns out, the guy has an ear wax fetish. Yup, he wanted me to use a Q-tip and clean out his ears. Then, he wanted to clean out mine. I couldn’t handle it and did everything I could to avoid the dreaded Q-tip. In the process of getting to know Ear Wax Boy, G got engaged. I was devastated, Ear Wax could sense I wasn’t ready to move on, and the romance ended”
- Extract 5: “I don’t know if this is a fetish or what but I will explain. I have a earwax problem, I get quite a bit of it in my ears if I don’t keep them cleaned out. I find myself during the day sticking pin lids and other skinny things into my ears and scraping the earwax out, which I’d say is normal but what isn’t normal is I enjoy smelling the ear wax. I really love the smell and I could sit all day with earwax up to my ears. I think smelling someone else’s would be sick, I only enjoy mine”
The first four of these are obviously sexually based while the final one borders more on non-sexual obsession (although I openly admit that it may not be a true obsession). I should also mention that the person in Extract 1 was also a self-admitted coprophile (with sexual fantasies and arousal involving diarrhea), and also appears to have macrophilc tendencies too (i.e., sexual arousal from giants). Additionally, the first two extracts may be the same person writing in two different online forums as the fantasy about being used as a Q-tip also appeared in both accounts (although I edited out this reference in Extract 2). There may be some psychological overlap between earwax fetishes and acnephilia (that I examined in a previous blog). For instance, I observed discussion of “earwax nirvana” on the Pop That Zit website.
Obviously, I have no idea if these online admissions are representative of earwax lovers (or how genuine the accounts are). As I said earlier, there is absolutely no academic or clinical research on the topic of earwax fetishes (and to be honest not likely to be as there doesn’t seem to be any problem associated with such behaviour).
Brown, D. (2008). The completely pointless Google experiment. November 17. Located at: http://dannybrown.me/2008/11/17/the-completely-pointless-google-experiment/
Choo, D. (2007). Japan hygiene. Culture Japan, August 10. Located at: http://www.dannychoo.com/post/en/1026/Japan+Hygiene.html
The Sportsman’s Daily (2010). Belichick one ups Rex Ryan; Admits to rare ear fetish. December 23. Located at: http://sportsmansdaily.com/thescrum/?p=3610
Wikipedia (2012). Earwax. Located at: http://en.wikipedia.org/wiki/Earwax
In previous blogs I have looked at both love addiction and obsessional love. Since writing my blog on obsessional love and noting that it is also known as erotomania, I have received a couple of emails from clinicians saying that obsessional love is not necessarily erotomania by definition. The problem with the wider area of obsessions, compulsions and addiction more generally is that academics and clinicians have different definitions of what it is to be obsessed or addicted to something.
In clinical circles, erotomania is known as de Clérambault’s syndrome (DCS), and was named after a paper published in 1921 (Les Psychoses Passionelles) by the French psychiatrist Gaëtan de Clérambault. Those with DCS typically have a delusional belief that another person (typically someone famous, high status and/or a stranger) is in love with them. Some of the scientific literature suggests that DCS sufferers may have experienced loss of people that were emotionally close to them, and that therefore they may feel emotionally and psychologically safer by attaching themselves to people who are unattainable. Such actions prevent any further losses. In a 1983 issue of Psychological Medicine, Dr. P. Taylor and colleagues described the main components of DCS:
- The presence of a delusion that the individual (usually described as a female) is loved by a specific man;
- The woman has had little or no contact with the man;
- The man is unattainable in some way, because he is already married or because he has no personal interest in her;
- The man is perceived as watching over, protecting or following the woman;
- Despite the erotic delusion, the woman remains chaste.
One of the reasons I am personally interested in DCS is that back in the early 1990s, my then girlfriend (who was – and still is – a clinical psychologist) was the object of affection by a DCS sufferer. The man who fell in love with my girlfriend was slightly brain damaged following a bad motorcycling accident. The accident had also left him paralyzed and had to use a wheelchair. As part of her job, my girlfriend worked with the charity Headway (a brain injury association), and it was when she was caring for this head injured and paralyzed man that he fell in love with her and believed that the feelings were reciprocal. The condition was so intense that he even booked a wedding date, sent out wedding invitations, and told all his family and friends that he was marrying my girlfriend. I even started to question my girlfriend’s fidelity because I couldn’t comprehend that someone could organize a whole wedding if nothing had ever happened between them. (Even though I was a psychologist when this happened I had never come across DCS).
The research literature on DCS suggests that the delusional behaviour is usually part of psychotic behaviour (typically schizophrenia, bipolar disorder, or borderline personality disorder) and can therefore be treated using atypical anti-psychotics (however, most DCS sufferers do not ask for help or seek treatment as they don’t believe they are doing anything wrong). According to the Wikipedia entry on DCS (and based on a paper published in a 1998 issue of the Journal of Neuropsychiatry and Clinical Neuroscience by Dr. C. Anderson and colleagues):
“During an erotomanic episode, the patient believes that a ‘secret admirer’ is declaring his or her affection to the patient, often by special glances, signals, telepathy, or messages through the media. Usually the patient then returns the perceived affection by means of letters, phone calls, gifts, and visits to the unwitting recipient. Even though these advances are unexpected and unwanted, any denial of affection by the object of this delusional love is dismissed by the patient as a ploy to conceal the forbidden love from the rest of the world”.
In a 2002 issue of the journal History of Psychiatry, Dr. German Berrios and Dr. N. Kennedy describe four convergences in the history of erotomania.
- Convergence 1: From classical times to the early eighteenth century, erotomania was viewed as a ‘general disease caused by unrequited love’.
- Convergence 2: During the nineteenth century, erotomania was viewed as a disease of ‘excessive physical love (nymphomania)’
- Convergence 3: During the twentieth century, erotomania was viewed as a form of ‘mental disorder’
- Convergence 4: Currently, erotomania is viewed as a ‘delusional belief of being loved by someone else’.
Berrios and Kennedy also note that there are differences between Anglo-Saxon and French views surrounding the meaning or coherence of “the much-abused English eponym ‘de Clérambault syndrome’. Erotomania is a construct, a mirror reflecting Western views on spiritual and physical love, sex, and gender inequality and abuse. On account of this, it is unlikely that there will ever be a final, ‘scientific’ definition rendering erotomania into a ‘natural kind’ and making it susceptible to brain localization and biological treatment”.
Empirical research suggests that women are more likely than men to suffer from DCS, and that DCS sufferers tend to have social and intimacy difficulties, and are therefore typically loners. Developmentally, they are likely to have a poor sense of self and may have suffered abuse during childhood and/or adolescence. Much of the published theorizing about erotomania is from a psychodynamic perspective or genetic/neurochemical presispositions. I’m far more eclectic in my approach to understanding human behaviour and believe that environmental, psychological, pharmacological and physiological factors most likely trigger a predisposed person into developing DCS. It’s also been speculated that learning through the media (television, radio, books, etc.) has influenced the development of DCS.
Dr. Louis Schlesinger in his 2004 book Sexual Murder: Catathymic and Compulsive Homicides writes about DCS sufferers in relation to possible stalking behaviour. He notes that: “some stalkers are unable to give up a prior intimate relationship (Zona, Sharma, and Lane, 1993). Some develop delusional beliefs about the target (Goldstein, 1987), while others develop strong obsessional thoughts about virtual strangers (Spitzberg and Cupach, 1994). Meloy (1992) and Kienlen (1998) believe that a disturbance of attachment begins in the offender’s early childhood and stalking starts when some type of loss in adulthood resurrects these early conflicts”
In some individuals, DCS can remain with the person for a long time. For instance, Dr. Harold Jordan and colleagues published a paper in a 2006 issue of the Journal of the National Medical Association. They reviewed two cases of DCS that they had followed for over 30 years “making these some of the longest, single-case longitudinal studies yet reported”. They noted that DCS remains a “ubiquitous nosological psychiatric entity with uncertain prognosis”. De Clerambault’s original paper presented the case of a woman whose chronic, erotic delusion remained with her for 37 years, and the cases reported by Dr. Jordan and his colleagues also demonstrated that the delusion can remain unchanged for decades. I have yet to come across any research that estimates the prevalence of DCS among the general population but given most published papers are clinical case reports, it suggests the disorder is relatively rare.
Anderson CA, Camp J, Filley CM (1998). Erotomania after aneurismal subarachnoid hemorrhage: Case report and literature review. Journal of Neuropsychiatry and Clinical Neuroscience, 10, 330-337.
Berrios G.E. & Kennedy, N. (2002). Erotomania: a conceptual history. History of Psychiatry, 13, 381-400.
Jordan, H.W., Lockert, E.W., Johnson-Warren, M., Cabell, C., Cooke, T., Greer, W. & Howe, G. (2006). Erotomania revisited: Thirty-four years later. Journal of the National Medical Association, 98, 487-793.
Schlesinger, L.B. (2004). Sexual murder: Catathymic and compulsive homicides. London: CRC Press.
Taylor, P., Mahendra, B. & Gunn J. (1983). Erotomania in males. Psychological Medicine, 13, 645-650.
Zona, M., Sharma, K., and Lane, J. (1993). A comparative study of erotomania and obsessional subjects in a forensic sample. Journal of Forensic Sciences, 38, 894–903.
In a previous blog I briefly looked at graphomania, which in a psychiatric context, relates to a morbid mental condition that manifests itself in written ramblings and confused statements. Graphomania in a non-psychiatric context typically concerns the urge or need to write to excess (and not necessarily in a professional context). Today’s blog looks at what I see as a sub-variant of this that has been termed ‘erotographomania’ although compared to ‘graphomania’ more generally, there seems to be a lot of different operational definitions of what erotographomania actually refers to. For instance:
- Dr. Anil Aggrawal’s book Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices defines erotographomania as when individuals derive sexual pleasure and arousal from writing love poems or letters.
- Like Dr. Aggrawal’s book, Dr. Brenda Love’s Encyclopedia of Unusual Sex Practices defines erotographomania as sexual arousal from writing love poems or letters but adds that the condition was “more common before the invention of the telephone”.
- In the 2005 edition of the Comprehensive Textbook of Sexual Medicine (edited by Dr. Nilamadhab Kar and Gopal Chandra Kar), erotographomania is defined as sexual gratification through obscene writing. Citing from Dr. J.B. Mukherjee’s 1985 book Forensic Medicine and Toxicology, it is reported that erotographomania comprises “drawing obscene pictures and diagrams in lavatories, public urinals or writing obscene anonymous letters to young girls”.
- In an article on ‘manifestly manifolded manias’ in a 1986 issue of the Journal of Recreational Linguistics, Paul Hellweg defined erotographomania as the “abnormal interest in erotic literature”.
- The Right Diagnosis website claims that erotographomania can comprise either and/or the (i) compulsive desire to write love letters, (ii) compulsive desire to write love poems, and (iii) abnormal interest in erotic literature. It also claims that treatment for the condition “may not be sought unless the condition becomes problematic for the person in some way, and they feel compelled to address their condition. Many people simply learn to accept their fetish and manage to achieve sexual gratification in a satisfactory manner”.
- The Encyclo (online encyclopedia) defines erotographomania as (i) an obsession to write love letters or to write erotic or pornographic literature, (ii) an abnormal interest in erotic literature, and (iii) in psychiatry, a morbid impulse to write love letters (generally written anonymously).
Obviously the numerous definitions outlined have clear overlaps, but there is no consensus on the exact erotic or (potentially paraphilic) focus. In my research for this article I couldn’t find a single academic or clinical article on the topic, just brief definitional mentions (of which the above list was comprised). Brenda Love’s comment (above) that the condition was more common before the telephone may be why there appear more mentions of the condition historically than in contemporary texts (for instance, erotographomania was mentioned in Edward Podolsky’s 1953 Encyclopedia of Aberrations, although again, there was no substance to what was written).
I did come across two books both entitled ‘Erotographomania’. The first was published in 2005 by Mike Martin (the full title of which was Erotographomania: Cruel Nostalgia), while the second one was published in 2008 by Rebecca Smith (and simply called Erotographomania). However, neither book was academic and neither provided any insight into the condition. I also came across an online academic article written in 2010 on love letters written by Kristine Trever. Writing about her own urges to write love letters:
“What happens to that urge to write out our love and desires and emotions in some concrete, tangible way to someone else..? And more importantly where does that urge come from?…I recall an overwhelming need to express something because of the influence of something else, because of an experience that touched me, reminded me, inspired me to share. I read a story that included a poem and through the existence of these two external items, the urge hooked me, the impulse too great to deny. I was overcome. The power of the pencil took over…If this all sounds crazy, impulsive, erratic, wild, unabashed and/or idiotic, itʼs critical to note that there is an actual disease called erotographomania, which is the compulsive act of writing and writing and writing and writing and writing and writing love letters. The OCD recipe for lovers”.
The Australian musician and songwriter Nick Cave gave a lecture in 1999 on love songs and claimed that he and a friend both had erotographomania. In his lecture he said:
“The reasons why I feel compelled to sit down and write love songs are legion. Some of these came clearer to me when I sat down with a friend of mine, who for the sake of his anonymity I will refer to as J.J. and I admitted to each other that we both suffered from psychological disorder that the medical profession call erotographomania. Erotographomania is the obsessive desire to write love letters. My friend shared that he had written and sent, over the last five years, more than seven thousand love letters to his wife. My friend looked exhausted and his shame was almost palpable. I suffer from the same disease but happily have yet to reach such an advanced stage as my poor friend J. We discussed the power of the love letter and found that it was, not surprisingly, very similar to the love song. Both served as extended meditations on ones beloved. Both served to shorten the distance between the writer and the recipient. Both held within them a permanence and power that the spoken word did not. Both were erotic exercises, in themselves. Both had the potential to reinvent, through words, like Pygmalion with his self-created lover of stone, one’s beloved. Alas, the most endearing form of correspondence, the love letter, like the love song has suffered at the hands of the cold speed of technology, at the carelessness and soullessness of our age”.
Maybe there is something in the Australian psyche when it comes to erotographomania as (during my research) I came across an Australian art exhibition on the topic that featured the work of Dejan Kaludjerovic, Claire Lambe, Nancy Mauro-Flude, Sally Rees, Noel Skrzypczak, Ben Terakes, and Paul Emmanuel. The exhibition was curated by Sarah Jones, who wrote that:
“Erotographomania (originally a term for perverse and obsessive love letter writing) aims to make parallels between the unconscious investment that artists make to address an audience and the intense erotic delusions played out in the exchange of love letters. Both produce a circuit of libidinal exchange that demands recognition. Both involve a fraught transferential displacement centred on an object of communication. Erotographomania explores pathos; the element of sadness and regret that flows between the ‘sender’ and the ‘addressee’ that becomes injected into the dubious presence of the world of objects; reflected there; contaminated by a past relentlessly regurgitated into the present. The exchange between the artist, the work and the audience remains confused and in flux, like that of the lover, the loved, the author and the intended beneficiary”.
Given an almost complete absence of academic and clinical reference to erotographomania, it begs the question of why it’s not been a topic of empirical investigation. Maybe the topic is being actively researched but no-one is calling it erotographomania. Many cyberpsychologists (including myself) have studied cybersexual behaviour that includes the sending of sexually arousing erotic emails to each other. Some of my academic papers on online sex (a few of which I’ve listed in the ‘further reading’ section below) make reference to online behaviours that fit some of the operational definitions of erotographomania outlined at the start of this article. Maybe it’s about time I wrote an article letting the cyberpsychology community know that they are simply researching an old phenomenon in a new environment.
Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.
Cave, N. (1999). Love Song Lecture September 25. Transcription of lecture at: http://everything2.com/title/Nick+Cave%2527s+Love+Song+Lecture
Encyclo Online Encyclopedia (2012). Erotographomania. Located at: http://www.encyclo.co.uk/define/erotographomania
Griffiths, M.D. (2000). Excessive internet use: Implications for sexual behavior. CyberPsychology and Behavior, 3, 537-552.
Griffiths, M.D. (2001). Sex on the internet: Observations and implications for sex addiction. Journal of Sex Research, 38, 333-342.
Griffiths, M.D. (2004). Sex addiction on the Internet. Janus Head: Journal of Interdisciplinary Studies in Literature, Continental Philosophy, Phenomenological Psychology and the Arts, 7(2), 188-217.
Griffiths, M.D. (2012). Internet sex addiction: A review of empirical research. Addiction Research and Theory, 20, 111-124.
Hellweg, P. (1986). Manifestly manifolded manias. Journal of Recreational Linguistics, 19(2), 100-108.
Kar, N. & Kar, G.C. (2005). Comprehensive Textbook of Sexual Medicine. New Delhi: Jaypee Brothers Medical Publishers.
Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.
Martin, M. (2005). Erotographomania: Cruel Nostalgia. BookSurge Publishing.
Mukherjee, J.B. (1985). Forensic Medicine and Toxicology. London: Academic Publishers.
Podolsky, E. (1953). Encyclopedia of Aberrations: A Psychiatric Handbook. London: Arco.
Right Diagnosis (2012). Erotographomania, February 1. http://www.rightdiagnosis.com/e/erotographomania/intro.htm
Smith, R. (2008). Erotographomania. Blurb Publishing (http://www.blurb.com/bookstore/detail/1468330)
Trever, K. (2010). How to write a love letter, or how do you write a love letter? Located at: http://www.kristinetrever.com/pdf/LoveLetter-Trever.pdf
In my previous blogs, I have looked separately at pregnancy delusions (i.e., women and men who think and claim they are pregnant but are not – including Couvade Syndrome) and culture bound syndromes (i.e., a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies). Since writing those blogs I unearthed a fascinating academic paper examining one of the strangest culture bound syndromes I have ever come across. While idly looking for some inspiration for a new blog, I happened (by chance) to come across a blog written in November 2011 by Jesse Bering on the Scientific American website which began with this opening paragraph.
“Are you suffering abdominal pain or discomfort, fatigue, nausea, flatulence, heartburn, and acid reflux? Have you been having difficulty urinating, or experiencing pain while doing so? Oh, and one other question – have you been spontaneously expelling microscopic bits of disintegrated dog fetuses through your urethra? If you answered “yes” to all of the above, then you may be suffering from “Puppy Pregnancy Syndrome”.
Bering’s report was based on a 2003 paper published in the International Journal of Social Psychiatry, entitled “Puppy pregnancy in humans: A culture-bound disorder in rural West Bengal, India”. The paper described a phenomenon that has only ever been reported in this one Indian area (near Kolkata) where both and women are convinced that it is possible to become pregnant and carrying a canine foetus if they are bitten by dogs – particularly if the dog is sexually aroused and because the dog’s saliva contains dog gametes. The phenomenon is a fairly recent one as there are few reports of ‘puppy pregnancy’ prior to 2000.
The paper, by Dr. Arabinda N. Chowdhury (Professor of the Institute of Psychiatry, Kolkata, India) and colleagues featured seven cases of people suffering from puppy pregnancy (six males and one female). The men claim to give birth to the puppies via their penis (in a similar excruciating fashion to the way that men have to pass kidney stones). At night, the female case claimed she could hear the puppies barking in her abdomen.
They also interviewed a further 42 adult villagers to see how prevalent the belief in puppy pregnancy was. They reported that three-quarters of the villagers interviewed believed with “definite certainty” that puppy pregnancy existed (73%), while only 9% had no belief in the phenomenon. In fact, it was reported that almost all the villagers could name someone whose unexplained death they believed was the direct consequence of a toxic puppy pregnancy (including those who were among the most well educated). The authors noted that in relation to the cases they outlined that:
“Psychiatric status showed that there was a clear association of obsessive-compulsive disorder in two cases, anxiety-phobic locus in one and three showed no other mental symptom except this solitary false belief and preoccupation about the puppy pregnancy…One case (11-year-old child) exemplified how the social imposition of this cultural belief made him a case that allegedly vomited out an embryo of a dog foetus… the cases presented a mix of somatic and psychological complaints and their help-seeking behaviour was marked”.
Due to the widespread belief in the existence of puppy pregnancy fact, the village community has their own “medical” specialists who “treat” the condition called bara ojhas. These so-called specialists provide remedies and/or perform abortion-inducing rituals. During the early stages of “pregnancy”, the use of herbal medicines by bara ojhas are said to help dissolve the puppy foetuses so that they are naturally expelled through the person’s genitals in an unobtrusive way. In Jesse Bering’s account of puppy pregnancy, he describes the case of a male:
“After one 24-year-old college graduate had an encounter with a stray dog that scratched him on the leg six months earlier, he became extremely wary of dogs because he was deathly afraid that one might knock him up. He was so preoccupied with dogs that even in the interview room he was apprehensive that a dog may come out from under the table. To address his unending circular ruminations about puppy pregnancy, his dog anxiety, and his obsessive-compulsive need to search for microscopic fetal canine parts in his urine, he was prescribed Clomipramine (an antidepressant) and Thioridazine (an antipsychotic). Importantly, he also underwent a month of behavioral reconditioning with a dog while being treated as an inpatient”.
Obviously, the condition may have no medical basis, but on a psychological level, the people in the Indian community experiencing a puppy pregnancy believe it is real. Dr. Chowdhury and colleagues believe that the crux of the condition is “the absence of any realistic consideration about the absurdity of asexual animal pregnancy and pregnancy in males (to the degree of delusional conviction).”
Dr. Chowdhury and colleagues believe that Puppy Pregnancy Syndrome meets the criteria for a genuine Culture-Bound Disorder because the mass delusional belief occurs as a consequence of “emotionally fuelled social transmission” only found in a very particular community (in this case, rural West Bengal), and that the disorder needs “proper cultural understanding for its effective management”.
Jesse Bering’s blog also made reference to another culture where giving birth to animals is a widely held belief. Bering cited the anthropologist E.E. Evans-Pritchard’s account of the Azande people in Africa who believe that some women can give birth to cats. I actually managed to get hold of Evans-Pritchard 1976 book Witchcraft, Oracles, and Magic among the Azande. The Azande believe that many animals are witches or dead witches inhabiting the animals. The most feared animal by the Azande are wildcats (called the adandara) that they believe have sex with female villagers. These women then allegedly give birth to kittens who are then said to breastfeed them like human children. The appendices in Evans-Pritchard’s book (based on his interviews with the Azande) reported:
“The male cats have sexual relations with women who give birth to kittens and suckle them like human infants. Everyone agrees that these cats exist and that it is fatal to see them…There are not many women who give birth to cats, only a few. An ordinary woman cannot bear cats but only a woman whose mother has borne cats can bear them after the manner of her mother”.
When interviewing Azande people, Evans-Pritchard said that his personal contacts included only two cases of people who had actually seen adandara. He then went on to note:
“Azande often refer to lesbian practices between women as adandara…This comparison is based upon the like inauspiciousness of both phenomena and on the fact that both are female actions which may cause the death of any man who witnesses them…Homosexual women are the sort who may well give birth to cats and be witches also. In giving birth to cats and in lesbianism the evil is associated with the sexual functions of women”.
Given that so little information was given in Evans-Pritchard’s book, I have no idea if the belief in adandara could be classed as a culture-bound syndrome, but there do seem to be similarities with Puppy Pregnancy Syndrome.
Bering, J. (2011). Puppy pregnancy syndrome: Men who think they are pregnant with dogs. Scientific American, November 15. Located at: http://blogs.scientificamerican.com/bering-in-mind/2011/11/15/puppy-pregnancy-syndrome-men-who-are-pregnant-with-dogs/
Chowdhury, A., Mukherjee, H., Ghosh, H.K. & Chowdhury, S. (2009). Puppy pregnancy in humans: A culture-bound disorder in rural West Bengal, India. International Journal of Social Psychiatry, 49, 35-42.
E.E. Evans-Pritchard (1976). Witchcraft, Oracles, and Magic among the Azande. Oxford: Clarendon Press.
Voice of America (2012). Bizarre medical myth persists in rural India.Located at: http://www.voanews.com/content/bizarre-medical-myth-persists-in-rural-india-143818636/179310.html