Category Archives: Psychiatry
Over the Christmas period, I was at a family wedding in the Cotswolds when by chance I came across Dr. Raj Persaud’s 2003 book From The Edge of the Couch (subtitled ‘Bizarre psychiatric cases and what they teach us about ourselves’) for sale in a charity shop in nearby Moreton-in-Marsh. As it was selling really cheaply I decided to buy it (even though this was the book where a number of the cases Dr. Persaud recounted were plagiarized from other people’s work).
One of the more interesting case studies in the book concerned a 1998 case study published by Dr. R.S. Shiwach and Dr. J. Prosser in the Journal of Sex and Marital Therapy. The paper concerned the treatment of an “unusual case of masochism” (where the individual gained sexual arousal and pleasure from being burnt (i.e., pyrophilia) and crushed (i.e., ‘crush fetishism’) that often meant he was in dangerous and potentially life threatening situations. As the authors summarized:
“Masochistic sexual activity is potentially dangerous, rarely reported voluntarily, and hard to treat. [Our paper] describes a masochist patient who received sexual gratification from being burnt or crushed. Anti-androgen medication [leuprolide acetate], serotonin uptake inhibitor [fluoxetine], and psychodynamic psychotherapy along with sexual education and social-skills training and aversive behavior therapy [covert sensitization and olfactory aversion] were all tried over a period of 9 months. The response was measured by effects of treatments on the frequency of erotic fantasies and masturbation”.
The male masochist was a single 38-year-old man that turned up at a hospital burns unit for treatment to extensive burns on his lower body (around 20% of his total body area) before being referred to the psychiatric unit. His pyrophilic urges and interest in being crushed were long-standing and dated back to mid-adolescence. The incident that led to the hospital admission had involved one of the man’s regular ways of gaining sexual arousal which was to set fire to refuse collecting trucks (i.e., ‘dumpsters’) while he was inside of them and simultaneously masturbating. Dr. Persaud’s reported that:
‘[The man] would then masturbate before getting out [of the dumpster]. His burns had occurred when a plastic dumpster melted and turned over. His first sexual experience at age 15 [years] had occurred when he curled himself up in an oven and ejaculated – an adventure that had been prompted by having been threatened as a child with being roasted ‘like a pig’ as a punishment. A social isolate, he enjoyed watching videos and reading about people being burned at the stake or crushed. He had also attempted autoerotic asphyxia, but relinquished this as ‘too dangerous’”.
The recollection of ejaculating while inside an oven appears to be a critical event in the acquisition and development of the man’s unusual sexual preferences. As Dr. Persaud noted:
“[The man remembered] entering a big unlit oven out of curiosity and liking the warmth and sense of suffocation but did not realize he had ejaculated until the third such instance. He remained a socially isolated virgin and gave a history of sexual disinterest in males or females and of ignorance of sexuality in general…Twice he came close to self-immolation after pouring gasoline on himself…he denied getting any pleasure out of seeing other people suffer…he worked in places where he could have easy access to large waste disposers, ovens, and box compactors”.
Consequently, Dr. Persaud thought (as I do) that learning theory best explained this man’s etiology and that psychoanalytic factors like guilt and punishment may have also been important. This particular case was also reported in a 2006 paper by Dr. D.J. Williams (i.e., ‘Different [painful) strokes for different folks) in the journal Sexual Addiction and Compulsivity. Williams noted that the man had been arrested on a number of different occasions for climbing into refuse collecting dumpsters and had also broken his pelvis as a consequence of being crushed by a box compactor. Williams noted that: “clearly, most experts would agree that acting out fantasies in these dangerous situations posed a significant risk of severe physical harm and death, not to mention being illegal”. Dr. Persaud’s account also more specifically reported that:
‘[The man] would climb into refuse collecting trucks and ejaculate at the sensation of being crushed, only escaping at the last possible minute. He admitted masturbating almost daily to deviant sexual fantasies or to pictures of fire, people being burned or crushed, and even just the sight of chimneys. Recently he had been climbing into a large dumpster, pouring alcohol on the refuse and setting it on fire. He managed to masturbate and get out of the refuse bin with minor burns twice, but the plastic dumpster eventually melted and overturned, causing the injuries he now had”.
Despite the many different pharmacological and psychological interventions, none appeared to have any long-lasting effect. The first intervention was pharmacological and involved being injected weekly with an anti-androgen. This treatment resulted in a decrease of his fetishistic sexual fantasies and an overall decrease in his sex drive. However, the man didn’t like the fact that his sex drive has been significantly inhibited and asked to be taken off the medication. He also took anti-depressants over an 18-week period and then had aversive behaviour therapy (olfaction aversion) and psychodynamic therapy, social skills training, and sexual education. He was discharged after 34 weeks of treatment but on follow-up had resumed his fetishistic behaviour. Drs. Shewach and Prosser concluded that: “Anti-androgens and aversive behavior therapies may be the most effective treatments for such cases, at least in the short-term, although the underlying social deficits and the need to reshape the sexual behavior ought to be addressed in the long-term”.
One of the observations that Dr. Persaud made about this case was that the masochism in this case did not involve psychological humiliation or any interaction with other people in the man’s life. I would also add that most of the focus and commentary in this particular case has been on the pyrophilic aspects rather than the crush fetishism aspects. This may be because there has been far less in the medical and clinical literature on crush fetishism than pyrophilia. However, this is not the only case where crush fetishism has been associated with another sexual paraphilia. At the end of last year, my case study of eproctophilia (i.e., sexual arousal from flatulence) in the Archives of Sexual Behavior involved an eproctophile that was also a crush fetishist.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Balachandra, K. & Swaminath, S. (2002). Fire fetishism in a female Aasonist? Canadian Journal of Psychiatry, 47, 487-488.
Bourget, D. & Bradford, J.M.W (1987). Fire fetishism, diagnostic and clinical implications: A review of two cases. Canadian Journal of Psychiatry 32, 459-462.
Griffiths, M.D. (2013). Eproctophilia in a young adult male: A case study. Archives of Sexual Behavior, 42, 1383-1386.
Litman, L.C. (1999). A case of pyrophilia. Canadian Psychological Association Bulletin, February, 18-20.
Persaud. R. (2003). From The Edge Of The Couch. London: Bantam Press.
Quinsey, V.L., Chaplin, T.C. & Upfold, D. (1989). Arsonists and sexual arousal to fire setting: Correlation unsupported, Canadian Journal of Behavior Therapy and Experimental Psychiatry, 20, 203-209.
Shiwach, R. S., & Prosser, J. (1998). Treatment of an unusual case of masochism. Journal of Sex and Marital Therapy, 24, 303-307.
Williams, D. J. (2006). Different (painful) strokes for different folks: A general overview of sexual sadomasochism (SM) and its diversity. Sexual Addiction and Compulsivity, 13, 333-346.
One of the more noticeable ‘extreme’ trends is that of body modification. Arguably the most common (and socially acceptable) forms of body modification are ear piercing and tattoos, followed by various other types of piercings (e.g., nipple piercings) and various types of plastic surgery (e.g., rhinoplasty [nose jobs] and breast augmentation [boob jobs]). More extreme types include foot binding, extreme corseting, branding, amputation, and genital cutting. Such types of actions are known as ‘acquired characteristics’ as they cannot be genetically passed on to the individuals’ children. As the body modification section of the Wikipedia entry on acquired characteristics notes:
“Body modification is the deliberate altering of the human body for any non-medical reason, such as aesthetics, sexual enhancement, a rite of passage, religious reasons, to display group membership or affiliation, to create body art, shock value, or self-expression. The frequency of occurrence depends on the location, extent, and number of modifications, and, perhaps most importantly, on the mind of each individual being asked to accept the modifications on another”.
In a recent issue of the Archives of Sexual Behavior, Dr. David Veale and Dr. Joe Daniels added that:
“Body modification is a term used to describe the deliberate altering of the human body for non-medical reasons (e.g., self-expression). It is invariably done either by the individual concerned or by a lay practitioner, usually because the individual cannot afford the fee or because it would transgress the ethical boundaries of a cosmetic surgeon. It appears to be a lifestyle choice and, in some instances, is part of a subculture of sadomasochism. It has existed in many different forms across different cultures and age”.
These definitions of body modification would also appear to include such practices as circumcision (although this may of course be done for legitimate medical reasons as well as cultural and/or religious rites of passage). Other ‘extreme’ forms of body modification include:
- Earlobe stretching: This refers to the gradual stretching of the earlobe through the gradual increase in size of piercing rings. This is typically carried out for aesthetic reasons, self-expression and/or group membership.
- Branding: This refers to the deliberate burning of the skin to produce an irreversible symbol, sign, ornament and/or pattern on human skin. This is typically carried out for group membership reasons (but can also be carried out for aesthetics and/or self-expression).
- Subdermal Implants (pocketing): This refers to a type of body jewelry placed underneath the skin and often used in conjunction with other forms of body modification. The body then ‘heals’ over the implant leading to a raised (sometimes 3-D) design. This is almost always done for aesthetic reasons and/or shock value.
- Extraocular implants: This refers to the placing of small pieces of jewelry in the eye by cutting the surface layer of the eye following a surgical incision. Again, this is almost always done for aesthetic reasons and/or shock value.
- Corneal tattooing: This is the practice of injecting a colour pigment into the eye. As with the previous two examples, this is almost always done for aesthetic reasons and/or shock value.
- Tongue splitting: This refers to the splitting of the tongue so that the tongue looks like (for instance) a serpent’s tongue.
- Tooth filing: This refers to the practice of filing teeth (often into the shape of sharp pointed fangs). This may be done for a variety of reasons including group membership, aesthetics and/or self-expression.
- Tightlacing (waist training, corset training): This refers to the use of incredibly tight fitting corsets (typically by women) to produce an archetypal ‘hourglass’ figure. This is typically carried out for aesthetic reasons.
- Pearling (genital beading): This refers to the permanent insertion of small beads beneath the skin of the genitals (such as the labia in women or the foreskin in men). Most of those who engage in pearling do it for aesthetic and/or sexual enhancement reasons (e.g., to increase sexual stimulation during vaginal or anal intercourse).
- Anal stretching: This refers to the gradual stretching of the anus with the use of specialized built for purpose ‘butt plugs’ (typically carried out for sexual enhancement and stimulation).
- Penis splitting (penile bisection): This is the cutting and splitting of a person’s penis from the glans towards the penis base (and which I covered at length – no pun intended – in a previous blog). This is typically done for reasons of sexual stimulation and fetishistic enhancement for either the self and/or sexual partner (although it has also been done for both religious and/or aesthetic reasons).
A really great 2007 review paper by Dr. Silke Wohlrab and colleagues in the journal Body Image examined all the known motivations for body modification (including tattoos and piercings) based on scientific studies and concluded almost all motivations fell into one or more of the following ten categories:
- Beauty, art, and fashion (i.e., body modification as a way of embellishing the body, achieving a fashion accessory and/or as a work of art).
- Individuality (i.e., body modification as a way of being special and distinctive, and creating and maintaining self-identity).
- Personal narratives (i.e., body modification as a form of personal catharsis, and/or self-expression. For instance, it was claimed that some abused women “create a new understanding of the injured part of the body and reclaim possession through the deliberate, painful procedure of body modification and the permanent marking”).
- Physical endurance (i.e., body modification as a way of testing a person’s own threshold for pain endurance, overcoming personal limits, etc.).
- Group affiliations and commitment (i.e., body modification as part of sub-cultural membership or the belonging to a certain social circle).
- Resistance (body modification as a protest against parents or society).
- Spirituality and cultural tradition (i.e., body modification as part of a spiritual or cultural movement).
- Addiction (i.e., body modification as a physical and/or psychological addiction due to (i) the release of endorphins associated with the pain of undergoing the practice, and/or (ii) the association with memories, experiences, values or spirituality).
- Sexual motivations (i.e., body modification as a way of enhancing sexual stimulation).
- No specific reason (i.e., body modification as an impulsive act without forethought or planning).
The review paper was incredibly thorough and these ten motivations cover everything they came across in the academic study of body modification. Unsurprisingly, the most frequently mentioned motivation was the expression of individuality and the embellishment of the own body. Hopefully I’ll cover some of the more specific body modifications in future blogs.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.
Lemma, A. (2010). Under the skin: A psychoanalytic study of body modification. London: Routledge.
Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.
Rowanchilde, R. (1996). Male genital modification. Human Nature, 7, 189-215.
Veale, D. & Daniels, J. (2012). Cosmetic clitoridectomy in a 33-year-old woman. Archives of Sex Behavior, 41, 725-730.
Wikipedia (2012). Acquired characteristic. Located at: http://en.wikipedia.org/wiki/Acquired_characteristic
Wikipedia (2012). Body modification. Located at: http://en.wikipedia.org/wiki/Body_modification
Wikipedia (2012). Penile subincision. Located at: http://en.wikipedia.org/wiki/Penile_subincision
Wohlrab, S., Stahl, J., & Kappeler, P. M. (2007). Modifying the body: Motivations for getting tattooed and pierced. Body image, 4, 87-95.
One of the most interesting psychological disorders is Münchausen Syndrome (MS) and is sometimes referred to more colloquially as ‘hospital addiction syndrome’, ‘hospital hopper syndrome’ and ‘thick chart syndrome’. MS is currently classified in the most recent International Classification of Diseases under ‘other disorders of adult personality’. The primary characteristic of people suffering from MS is that they deliberately pretend to be ill in the absence of external incentives (such as criminal prosecution or financial gain). MS has been called a factitious disorder because sufferers feign illness, pretend to have a disease, and/or fake psychological trauma typically to gain attention and/or sympathy from other people. Doctors often nickname such people as ‘frequent flyers’. The name of the syndrome was coined in 1951 by Dr. Richard Asher (in a paper he published in The Lancet about people who fabricated illnesses) and derives from German Karl Friedrich Hieronymus Freiherr von Münchhausen (aka Baron Münchausen), a renowned eighteenth century nobleman, who was reported as telling many fantastical and impossible stories about himself.
A related condition is Münchausen Syndrome by Proxy refers to the abuse of someone else (quite often a child son or daughter), also as a way of seeking attention and/or sympathy for the sufferer. Some members of the medical community believe that this related MS condition should simply be re-named ‘medical abuse’). There are also some specific sub-types of MS. For instance, a 2011 paper in the Journal of Electrocardiology, by Dr. Joseph Vaglio reported a female case of Arrhythmogenic Münchausen Syndrome who intentionally simulated and stimulated irregular cardiac activity to gain medical attention by drinking (and overdosing) on caffeine.
According to Dr. A.J. Giannini and Dr. H.R. Black in the Psychiatric, Psychogenic and Somatopsychic Disorders Handbook, one of the most common signs among MS sufferers is that they may have multiple scars on their abdomen because of repeated exploratory or emergency operations. Other ‘warning signs’ listed on the Web MD website of MS include: (i) dramatic but inconsistent medical history, (ii) predictable relapses following improvement in the condition, (iii) detailed knowledge of hospitals and/or medical terminology, (iv) appearance of new or additional symptoms following negative test results, (v) willingness or eagerness to have medical procedures, (vi) history of seeking treatment at numerous hospitals, clinics, and doctors offices, possibly even in different cities, and (vii) problems with identity and self-esteem.
There has been a debate about whether MS should have been re-classified in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. For instance, in a 2008 issue of the journal Psychosomatics, Dr. Lois Krahn and her colleagues argued that MS should be classed as a somatoform disorder because MS sufferers may not be conscious that they are drawing attention to themselves. [According to Wikipedia, a somatoform disorder “is a mental disorder characterized by symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder”]. More specifically, Krahn and her colleagues noted:
“Factitious and somatoform-disorder patients are alike in that they both organize their lives around seeking medical services in spite of having primarily a psychiatric condition. In DSM–IV, the key difference is that factitious-disorder patients feign illness, and somatoform disorder patients actually believe they are ill. Although patients may not be conscious of their motivation or even their behaviors, deliberately embellishing history or inducing symptoms exemplifies behaviors designed to enhance a self-concept of being ill. For DSM–V, we propose reclassifying factitious disorder as a subtype within the somatoform-spectrum disorders or the proposed physical-symptom disorder, premised on our belief that deliberate deceptions serve primarily to portray to treaters the sense of being ill”.
This appears to be part of the same debate that says MS is distinct from hypochondriasis in that MS patients are said to be aware that they are exaggerating their illness or disease, whereas hypochondriasis sufferers actually believe they have an illness or disease. Another way of looking at it is that MS sufferers want to be a patient whereas those with hypochondriasis don’t. One of the more unusual consequences of MS is that the affected individual will often undergo unnecessary medical procedures, treatments and/or exploratory operations to prolong hospital stay and gain sympathy and attention from those around them including the medical and nursing staff. It is also known that some MS patients have very good medical knowledge and use this as a way of creating and/or producing symptoms of known medical conditions.
Some of the reported risk factors for individuals that develop MS include (i) a history of childhood traumas and (ii) emotional deprivation (e.g., having parents or guardians that were emotionally unavailable due to illness and/or emotional problems while the individual was a child). In relation to treatment and prognosis, the Wikipedia entry on MS asserts:
“Providers need to acknowledge that there is uncertainty in treating suspected Münchausen patients so that real diseases are not under-treated. Then they should take a careful patient history and seek medical records, to look for early deprivation, childhood abuse, or mental illness. If a patient is at risk to himself or herself, inpatient psychiatric hospitalization should be initiated…Therapeutic and medical treatment should center on the underlying psychiatric disorder: a mood disorder, an anxiety disorder, or borderline personality disorder. The patient’s prognosis depends upon the category under which the underlying disorder falls; depression and anxiety, for example, generally respond well to medication and/or cognitive-behavioral therapy, whereas borderline personality disorder, like all personality disorders is presumed to be pervasive and more stable over time, thus offers the worst or best prognosis”.
Unfortunately there are no reliable statistics regarding the number of people who suffer from MS. Research suggests that both males and females are affected in roughly equal numbers and that the mean age of presentation is 36-years old. This is certainly one behaviour that we could do with more empirical research.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Asher, R. (1951). Munchausen’s syndrome. The Lancet, 1, 339–341.
Bhugra D. (1988). Psychiatric Munchausen’s syndrome. Literature review with case reports. Acta Psychiatrica Scandinavica, 77, 497–503.
Feldman, M.D., Hamilton, J.C & Deemer, H.N. (2001). Factitious Disorder. In K.A. Phillips (Eds.), Somatoform and Factitious Disorders. Washington D.C.: American Psychiatric Association.
Giannini A.J. & HR Black, H.R. (1978). Psychiatric, Psychogenic and Somatopsychic Disorders Handbook (pp.194-195). New Hyde Park, NY. Medical Examination Publishing.
Krahn, L.E., Bostwick, J.M. & Stonnington, C.M. (2008). Looking toward DSM-V: Should factitious disorder become a subtype of somatoform disorder? Psychosomatics, 49, 277–282.
Vaglio, J. C., Schoenhard, J. A., Saavedra, P. J., Williams, S. R., & Raj, S. R. (2011). Arrhythmogenic Munchausen syndrome culminating in caffeine-induced ventricular tachycardia. Journal of Electrocardiology, 44, 229-231.
Wikipedia (2013). Münchausen syndrome. Located at: http://en.wikipedia.org/wiki/Münchausen_syndrome
In 1984, Dr. Milton Burglass and Dr. Howard Shaffer published a paper in the journal Addictive Behaviors and claimed that arguably the important questions in the addiction field are ‘why do people become addicted to some things and not others?’ and ‘why some people become addicted and not others?’ Answers to these questions have been hindered by two common misconceptions about addiction, which to some extent have underpinned the ‘hard core’ disease concept of addiction. These are that addiction somehow resides within: (i) particular types of people or (ii) particular substances, and/or particular kinds of activity. That is, either some people are already ‘diseased,’ or else some substances/ activities cause this disease, or both.
There is a belief that some people are destined to become addicted. Typically this is explained in one (or both) of two ways. That some people (i.e., ‘addicts’) have an addictive personality, and that there is a genetic basis for addiction. The evidence for ‘addictive personality’ rests to a certain extent upon one’s faith in the validity of psychometric testing. Setting aside this major hurdle, the evidence in this area (as I argued with my colleagues Dr. Michael Larkin and Dr. Richard Wood in a 2006 issue of Addiction Research and Theory [ART]) is still inconclusive and contradictory.
First, psychologists have yet to determine which particular personality traits are linked to addiction. Studies have claimed that ‘the addictive personality’ may be characterized by a wide range of factors (e.g., sensation-seeking, novelty-seeking, extroversion, locus-of-control preferences, major traumatic life events, learned behaviours, etc.). The extent of this range stretches not only the notion of an ‘addictive personality’ but also the concept of ‘personality’ itself. Inevitably, much of this work relies on correlation analysis, and so the interpretation of results is not easily framed in terms of cause and effect. The approach is overly simplistic and is underpinned by a simple proposition that if we can divide people up into the right groups, then the explanation will emerge. However, addiction is far more complex than this. Of course, the relationship between individual bodies, minds, contexts, and life histories is complex and important – but it requires that we approach the matter from a more sophisticated and integrative position.
The search for a genetic basis for addiction rests upon the notion that some types of individuals are somehow ‘biologically wired’ to become addicts. In our 2006 ART paper, we argued that we must set aside any doubts about the limited conceptualization of ‘the environment’ that often typifies this kind of research, and its combination with epidemiological designs that are largely descriptive. Meta-analytic reviews have concluded that the heritability of addictive behaviour is likely to be controlled by many genes each contributing a small fraction of the overall risk. Furthermore, some of these same genes appear to be risk factors for other problems, some of them conceptually unrelated to addiction. We argued that the main point here is that while these findings do contribute something to our understanding of ‘why some people and not others,’ they do not adequately or independently explain the range of variation. Therefore the most we can say is that some people are more likely to develop problems under certain conditions, and that given the right conditions most people could probably develop an addiction. Emphasis needs to be placed on identifying those ‘conditions,’ rather than on searching for the narrowest of reductionist explanations.
We also argued in our 2006 ART paper that substances and activities cannot be described as intrinsically addictive in themselves (unless one chooses to define ‘addictive’ in terms of a substance or behaviour’s ability to produce tolerance and/or withdrawal, and to ignore the range of human experience that is excluded by this). Biologists may be able to tell us very valuable things about the psychopharmacological nature of the rewards that particular substances and behaviours provide, and the different kinds of neuroadaptation that they may or may not produce in order to effect tolerance and/or withdrawal. But we argue that this on its own, is not an adequate explanation for addiction. In 1975, Dr. Lee Robins’ classic study (in the Archives of General Psychiatry) of heroin-users returning from the Vietnam war is one example of the evidence that refutes this oversimplification. This study clearly highlighted the importance of context (i.e., that in a war zone environment individuals were addicted to heroin but on return to civilian life the addiction ceased to exist), and the framework provided by such contexts for making sense of addiction. In a hostile and threatening environment, opiates clearly provided something not usually required by most people; and given a cultural environment in which opiate use is a commonplace, and opiates are available, then opiate use ‘makes sense’. This study provides support for the assertion that some people are more likely to become addicted under some conditions, and that given the right conditions perhaps many people could understand what it means to be an addict.
So, with regard to the question, ‘why some individuals/addictions and not others?’ the rewards associated with various activities may be qualitatively very different, and may not necessarily be inherent or unique to a particular activity or substance, either. Many rewarding activities are rewarding because they present individuals with opportunities to ‘shift’ their own subjective experience of themselves (for example, see the research on Ecstasy use and bungee jumping that I published with Dr. Michael Larkin in a 2004 issue of the Journal of Community and Applied Social Psychology).
Frequently, a range of such opportunities is offered to the experienced user. Dr. Howard Shaffer (in a 1996 paper in the Journal of Gambling Studies) has pointed out that those activities that can be most relied upon to shift self-experience in a robust manner are likely to be the most popular – and (as a consequence) to be the most frequent basis of problems. So, obviously, our understanding of the available resources for mood modification must play a major part in understanding addiction. However, we must make a careful distinction between describing some substances as being more ‘robust shifters of experience’ than others (as we advocated in our 2006 ART paper) and describing some substances as ‘more addictive’ than others (which we argued against).
Burglass, M.E. & Shaffer, H.J. (1984). Diagnosis in the addictions I: Conceptual problems. Addictive Behaviors, 3, 19-34.
Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.
Griffiths, M.D. (2011). Behavioural addiction: The case for a biopsychosocial approach. Transgressive Culture, 1(1), 7-28.
Griffiths, M.D. & Larkin, M. (2004). Conceptualizing addiction: The case for a ‘complex systems’ account. Addiction Research and Theory, 12, 99-102.
Larkin, M., Wood, R.T.A. & Griffiths, M.D. (2006). Towards addiction as relationship. Addiction Research and Theory, 14, 207-215.
Orford, J. (2001). Excessive Appetites: A Psychological View of the Addictions (Second Edition). Chichester: Wiley.
Robins, L.N, Helzer, J.E, & Davis, D.H (1975) Narcotic use in Southeast Asia and afterward. Archives of General Psychiatry, 32, 955-961.
Shaffer, H. J. (1996). Understanding the means and objects of addiction: Technology, the Internet, and gambling. Journal of Gambling Studies, 12, 461–469.
Tyndale, R.F. (2003). Genetics of alcohol use and tobacco use in humans. Annals of Medicine, 35(2), 94–121.
Walters, G. D. (2002). The heritability of alcohol use and dependence: A meta-analysis of behavior genetic research. American Journal of Drug and Alcohol Abuse, 28, 557–584.
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.).
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”
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”
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.