Category Archives: Psychiatry
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
Just recently (and quite by accident while I was doing some research into fingernail fetishes – the topic of an upcoming blog) I came across a case study of an allegedly unique sexual paraphilia called ‘Sleeping Beauty’ paraphilia. The paper was by Dr. Francesco Bianchi-Demicheli and three colleagues, and published in a 2010 issue of the journal Medical Science Monitor. The case involved a 34-year old married man who was admitted to a psychiatric unit in February 2007 following a violent physical attack on his wife. The marriage had been failing for a number of years because of the man’s paraphilic actions in which his wife was an unwilling participant.
The man’s sexual focus was arousal from seeing women sleeping. This as I have written about in a previous blog on somnophilia is not unheard of. (Somnophilia is a sexual paraphilia in which sexual arousal is derived from intruding on, caressing, and/or fondling someone – typically a stranger – while they are asleep without force or violence.) However, where the paraphilia differed from ‘classic’ somnophilia was that the man liked to look after the woman’s hands and nails while they were asleep (this helps explain why I came across the case while researching into fingernail fetishism). The man also had an idealized routine and would always start with the women’s right hand before moving on to the left. Over the years of the marriage, the urge to control his paraphilic interest worsened. At the start of his marriage he used to give his wife sleeping pills that she consented to take. However, the wife eventually refused to take the medication given by her husband. Consequently, the man began to surreptitiously administer sleeping pills (the benzodiazepine Bromaezepam) to his wife without her knowledge. In 2006, the man’s wife discovered what her husband had been doing and the relationship deteriorated even further. The authors wrote that:
“Because of the extremely powerful obsession with sleeping women and painting their nails, the patient disguised himself with a latex mask and attacked his wife, as she returned from work, with an Olerosin Capsicum (OC) spray, to anaesthetize her. During this episode, his wife succeeded in taking off his mask, escaped and called the police who brought him to the psychiatric emergencies”.
Following a psychiatric assessment that was deemed “normal” the man revealed that when he was 10 years old he had an incident of head trauma that resulted in a four-day long coma. He subsequently received various neurological evaluations, including neuroimaging brain scans. The authors reported that:
“The cerebral MRI showed a moderate atrophy in the fronto-parietal region with a diffuse and severe white matter injury compatible with his previous head trauma. On a functional viewpoint, this brain network is known to sustain among others, the sense of self, body-image, and attention mechanisms. His neuropsychological exam was in line with this assumption. The patient was diagnosed with a moderate dysexecutive syndrome and a very specific body image disorder characterized by an incomplete mental image of his hands, mostly the right (i.e., personal representational hemineglect), as ascertained by his graphical representation of his body parts. The clinical hypothesis was that the paraphilia might be related to his post-traumatic disturbed body image and more specifically to the incomplete hands representation”.
The authors made reference to a number of studies that suggest paraphilic behaviour can appear following brain damage (see ‘Further reading’ below) and concluded that their case study highlighted “the potential link between paraphilia, deviant and aggressive sexual behaviour, neurological disturbance and self-representation…Presumably, the occurrence of head trauma leading to catatonia in adolescents might have played a critical role on the development of his sexual self and body image”.
A good critique of this particular case study was by The Neurocritic who wrote that:
“One puzzling aspect of this case is why the ‘Sleeping beauty paraphilia’ became uncontrollable only in adulthood, showing a progressive escalation during his marriage. This might be suggestive of a neurodegenerative disorder, but that was not part of his diagnosis. And I’m not sure why an old traumatic brain injury would have lead to ‘moderate’ atrophy in the fronto-parietal region. I might have expected more involvement of the orbitofrintal cortex, given the nature of the patient’s behavioral changes. However, many other examples of impulsive sexual offenses are even less obviously related to neurological status (e.g., after head injuries when the damage might not be visible on an MRI scan, and of course the population of offenders who have never sustained a TBI [traumatic brain injury]). Since the lesions were distributed and not focal, a final mystery is why the body image disturbance was confined to the right hand (implying a left hemisphere origin). This type of personal representational hemineglect (neglect for a mental representation of one side of the body) is most often associated with lesions in the right hemisphere”.
The Neurocritic also makes a point that I have raised in other blogs that I’ve written on various paraphilias concerning the issue of whether something is problematic if there is a willing participant to share the sexual urges. The Neurocritic concludes:
“What is considered acceptable can vary widely across cultures and subcultures (Bhugra et al, 2010) and across individuals. If the patient of Bianchi-Demicheli et al. found a partner willing to have her fingernails done while sedated with sleeping pills, perhaps the classification would change from paraphilic disorder to something that might be considered strange and paraphilic to most people, but causing no distress to the two willing participants”
Personally, I feel this paraphilic behaviour is just a sub-type of somnophilia or somnophilia overlapping with hand fetishism. However. Given the complete lack of case studies ion the clinical literature on somnophilia, who is to say that this case study is not representative of somnophiles more generally?
Bianchi-Demicheli F, Rollini C, Lovblad K, & Ortigue S (2010). “Sleeping Beauty paraphilia”: Deviant desire in the context of bodily self-image disturbance in a patient with a fronto-parietal traumatic brain injury. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 16(2), C15-C17.
Bhugra D, Popelyuk D, McMullen I. (2010). Paraphilias across cultures: Contexts and controversies. Journal of Sex Research, 47, 242-56.
Briken, P., Habermann, N., Berner, W. & Hill, A. (2005). The influence of brain abnormalities on psychosocial development, criminal history and paraphilias in sexual murders. Journal of Forensic Science, 50, 1204-1208.
Lehne G.K. (1994). Brain damage and paraphilia treated with medroxyprogesterone acetate. Sex and Disability, 10, 145–158.
Miller, B.L., Cummings, J.L,. McIntyre H et al (1986). Hypersexuality or altered sexual preference following brain injury. Journal of Neurology, Neurosurgery and Psychiatry, 49, 867–873
The Neurocritic (2010). “Sleeping Beauty Paraphilia” and Body Image Disturbance After Brain Injury. April 11. Located at: http://neurocritic.blogspot.co.uk/2010/04/sleeping-beauty-paraphilia-and-body.html
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.
I recently published a potentially controversial paper in the journal Frontiers in Psychiatry arguing that loss of control may not always be a natural consequence of addiction. Research into addiction has a long history although there has always been much debate as to what the key components of addiction are. Irrespective of the theory and model of addiction, most theorizing on addiction tends to assume (implicitly or explicitly) that ‘loss of control’ is central (if not fundamental) to addiction. My paper challenges such notions by arguing that there are a minority of individuals who appear to be addicted to a behaviour (i.e., work) but do not necessarily appear to display any loss of control.
Research into many different types of addiction has shown that addicts are not a homogeneous group, and this may also have implications surrounding control and loss of control. Many years ago, in my 1995 book Adolescent Gambling, I argued that in relation to problem gambling there appear to be at least two sub-types of addiction – primary addictions and secondary addictions. I defined primary addictions as those in which a person is addicted to the activity itself, and that individuals love engaging in the activity whether it is gambling, sex or playing video games. Here, the behaviour is primarily engaged in to get aroused, excited, and/or to get a ‘buzz’ or ‘high’. I defined secondary addictions as those in which the person engages in the behaviour as a way of dealing with other underlying problems (i.e., the addiction is symptomatic of other underlying problems). Here the behaviour is primarily engaged in to escape, to numb, to de-stress, and/or to relax.
Therapeutically, I argued that it is easier to treat secondary addictions. My argument was that if the underlying problem is addressed (e.g., depression), the addictive behaviour should diminish and/or disappear. Primary addicts appear to be more resistant to treatment because they genuinely love the behaviour (even though it may be causing major problems in their life). Furthermore, the very existence of primary addictions challenges the idea that loss of control is fundamental to definitions and concepts of addiction. Clearly, people with primary addictions have almost no desire to stop or cut down their behaviour of choice because it is something they believe is life affirming and central to the identity of who they are. But does lack of a desire to stop the behaviour they love prevent ‘loss of control’ from occurring? Arguably it does, particularly when examining the research on workaholism.
I have popularized the ‘addiction components model’, particularly in relation to behavioural addiction (i.e., non-chemical addictions that do not involve the ingestion of a psychoactive substance). The addiction components model operationally defines addictive activity as any behaviour that features what I believe are the six core components of addiction (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict and relapse, and which I outlined in my very first blog on this site)
One of the observations that can be made by examining these six criteria is that ‘loss of control’ is not one of the necessary components for an individual to be defined as addicted to an activity. Although I acknowledge that ‘loss of control’ can occur in many (if not most) addicts, loss of control is subsumed within the ‘conflict’ component rather than a core component in and of itself. The main reason for this is because I believe that there are some addictions – particularly behavioural addictions such as workaholism – where the person may be addicted without necessarily losing control. However, such a claim depends on how ‘loss of control’ is defined and the highlights the ambiguity in our standard understanding of addiction (i.e., the ambiguity of control as ability/means versus control as goal/end).
When theorists define and conceptualise ‘loss of control’ as applied to addictive behaviour, it typically refers to (i) the loss of the ability to regulate and control the behaviour, (ii) the loss of ability to choose between a range of behavioural options, and/or (iii) the lack of resistance to prevent engagement in the behaviour. In some behaviours such as workaholism and anorexia, the person arguably tries to achieve control in some way (i.e., over their work in the case of a workaholic, or over food in the case of an anorexic). However, this in itself is not a counter-example to the idea that addiction is a ‘loss of control’ if workaholics and anorexics have lost the ability to control other aspects of their day-to-day lives in their pursuit of control over work or food (i.e., there is a difference between control as the goal/end of behaviour, and control as an ability/means.
There is an abundance of research indicating that one of the key indicators of workaholism (alongside such behaviours as high performance standards, long working hours, working outside of work hours, and personal identification with the job) is that of control of work activities. In a recent paper I wrote with my colleague Dr. Maria Karanika-Murray in the Journal of Behavioral Addictions, we also noted that the need for control is high among workaholics, and as a consequence they have difficulty in disengaging from work leading to many other negative detrimental effects on their life such as relationship breakdowns. Even some of the instruments developed to assess workaholism utilize questions concerning the need to be in control.
There are also other studies that suggest some workaholics do not experience a ‘loss of control’ in the traditional sense that is used elsewhere in the addiction literature. For instance, in a 2004 issue of the Journal of Organizational Change Management, Dr. Peter Mudrack reported that two particular aspects of obsessive-compulsive personality (i.e., being stubborn and highly responsible) were predictive of workaholism. A very recent paper by Dr. Ayesha Tabassum and Dr. Tasnuva Rahman in the International Journal of Research Studies in Psychology noted that perfectionist workaholics experience an overbearing need for control and are very scrupulous and detail-oriented about their work. Unusually among addictions, workaholics usually have no desire to reduce or regulate their work behaviour (i.e., there is no ambivalence or conflicting desire for them). In this instance, there is no evidence of ‘loss of control’ as traditionally understood, because if they had ambivalent or conflicting desires, they would change their behaviour (i.e., reduce the amount of time they spend working). Although not an exhaustive list of studies, those mentioned here appear to indicate that some workaholics appear to be more in control than not in control.
When the addiction is primary, the goal/end of the behaviour is desired and/or endorsed without ambivalence by the addict. In these situations (as in some cases of workaholism), there is no evidence for loss of control, because no (failed) attempts are made by the addict to alter their behaviour. However, this could arguably still be compatible with the claim that there is loss of control in the sense of ability and/or means, because, if the workaholic tried to work less (or work in a less controlling way) because they started to recognize ill effects the addictive behaviour was having on their personal life, then they may fail to do so. Therefore, the lack of evidence is indicative rather than conclusive.
However, one of the reasons that workaholism raises interesting theoretical and conceptual issues concerning the loss of control is that it is an example of an addiction where the goal/end is itself a form of control (i.e., control over their productivity/outputs, control over others, control over time-keeping, etc.). Unlike many other addictions, such behaviour is not impulsive and/or chaotic but carefully planned and executed. So this raises the question, in what sense is workaholism a loss of control, understood in the typical way, as ability/means to the behaviour’s goal/end? In some cases of workaholism, there is no evidence that the workaholic lacks control over this goal/end, as they do not try to change their behaviour (and thus cannot fail to do so).
It could be argued – and this is admittedly speculative – that ‘loss of control’ as is traditionally understood appears to have a greater association with secondary addiction (i.e., where an individual’s addiction is symptomatic of other underlying problems) than primary (or ‘happy’ or ‘positive’) addiction (i.e., where an individual feels totally rewarded by the activity despite the negative consequences). Such a speculation has good face validity but needs empirical testing. However, a complicating factor is the fact that my studies on adolescent gambling addicts have demonstrated that some individuals start out as primary addicts but became secondary addicts over time. Again, this suggests that control (and loss of it) may be something that changes its nature over time.
In essence, workaholics appear to make poor choices and/or decisions that have wide-reaching detrimental consequences in their lives. However, at present we lack evidence that (should they decide otherwise) they would be unable to work in a more healthy way. Furthermore, and equally as important, the nature of workaholic behaviour is not impulsive and chaotic, but carefully planned and executed. This is particularly striking among some workaholics, because as I have noted, it is an addiction that for some individuals they continue to work happily despite objectively negative consequences (e.g., relationship breakdowns, neglect of parental duties, etc.). What the empirical research on workaholism suggests is that it is an example of an addiction in which the problem is better characterized as loss of prudence rather than loss of control, as traditionally understood.
Andreassen, C.S., Griffiths, M.D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.
Andreassen, C. S., Torsheim, T., Brunborg, G. S., & Pallesen, S. (2012) Development of a Facebook addiction scale. Psychological Reports, 110, 501-517.
Griffiths, M.D. (1995). Adolescent Gambling. London: Routledge.
Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.
Griffiths, M.D. (2011). Workaholism: A 21st century addiction. The Psychologist: Bulletin of the British Psychological Society, 24, 740-744.
Griffiths, M.D. & Karanika-Murray, M. (2012). Contextualising over-engagement in work: Towards a more global understanding of workaholism as an addiction. Journal of Behavioral Addictions, 1(3), 87-95.
Mudrack, P.E. (2004). Job involvement, obsessive-compulsive personality traits, and workaholic behavioral tendencies. Journal of Organizational Change Management, 17, 490-508.
Mudrack, P.E. & Naughton, T.J. (2001) The assessment of workaholism as behavioral tendencies: Scale development and preliminary empirical testing. International Journal of Stress Management, 8, 93-111.
Tabassum, A. & Rahman, T. (2012). Gaining the insight of workaholism, its nature and its outcome: A literature review. International Journal of Research Studies in Psychology, 2, 81-92.