“Although some authors have defined the focus of coprophilia as the act of elimination (McCary, 1967), others have defined it as the act of consumption of excrement (Allen, 1969). To complicate the definition further, it appears that some individuals may have an interest in eliminating on one’s partner or in playing with the fecal matter. According to Smith (1976), a common analytic interpretation is that the excrement symbolically represents the penis and that the presence of the fecal matter serves as a defense against castration anxiety”

In the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV), it is classified under ‘Paraphilia Not Otherwise Specified’ (PNOS) along with other paraphilias such as necrophilia, zoophilia, klismaphilia, and telephone scatophilia. As with all paraphilias in the PNOS category, diagnosis is only made “if the behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning…Fantasies, behaviors, or objects are paraphilic only when they lead to clinically significant distress or impairment (e.g., are obligatory, result in sexual dysfunction, require participation of non-consenting individuals, lead to legal complications, interfere with social relationships)”. The psychologist Dr Tamara Penix (Eastern Michigan University, USA) says there are no data indicating successful treatment of coprophilia.

Surprisingly little scientific research has been carried out on coprophilia, probably because it is so rare. There are certainly pornographic films that include sexual defecation acts (notably some Japanese pornography). Some of these films include coprophiliacs engage in coprophagia (i.e., the eating of faeces and typically referred to more commonly as ‘scat’) which can provides a significant health risk in the form of hepatitis (perhaps another reason as to why the act is so rare). The psychiatrist, Dr Charles Lake (University of Kansa Medical Center, USA) notes that both coprophilia and coprophagia are traditionally considered characteristics of schizophrenia. However, there are case reports in the literature of non-psychotic coprophiliacs with normal intelligence such as one published in the Journal of Sex and Marital Therapy in 1995.

The most infamous copraphiliac was allegedly Adolf Hitler. This was alluded to in a recent 2011 biography of Hitler’s lover Eva Braun by Heike B. Gortemaker. However, other books on Hitler have been more explicit. For instance, Greg Hallet in his chapter ‘Hitler’s Sexuality’ (from his 2008 book ‘Hitler was a British Agent’) wrote:

“Hitler’s close boyhood friend from Linz, August Kubizek, wrote Adolf Hitler, Mein Jugendfreund (My Youth Friend), ‘Adolf did not engage in love affairs or flirtations. He always rejected the coquettish advances of girls or women. Women and girls took an interest in him but he always evaded their endeavours’…During deconstruction, it is customary that the person is sexually abused in the manner which is most embarrassing to that person. In Hitler’s case, he was sodomised, creating a submissive distant respect for homosexuals like his bodyguards and some of his highest-placed leaders. His natural bent was developed into coprophilia (being shat on)…With each deconstruction an embarrassing addiction is developed and filmed. With Hitler it was sadomasochism, coprophilia and homosexuality. That is, he liked to be verbally abused and slapped around, to have his head urinated on, his chest shat on, and to have sex with men”

The few studies that have been carried out have tended to be done on sadomasochist individuals (although even for sadomasochists this appears to be a rare activity for them to engage in). A study led by psychologist Dr Kenneth Sandnabba (Åbo Akademi University, Turku, Finland) and published in the Journal of Sex Research surveyed 164 Finnish male sadomasochists and reported that that 18% of them had engaged in at least one coprophilic act (6% as a masochist, 3% as a sadist, and 9% as both). There was no difference in sexual orientation with 18% of heterosexual sadomasochists and 17% of homosexual sadomasochists having engaged in at least one coprophilic act. The results also showed that the sadomasochists were socially well-adjusted and that their SM behavior was mainly a facilitative aspect of their sexual lives.

In a follow-up study published in the journal Deviant Behavior, Sandnabba and colleagues analysed data from a subset of twelve men from their study of sadomasochists who had also engaged in zoophilic activities. This group was then compared with a control group of sadomasochists from the same data set but who had not engaged in zoophilic activities. Results showed seven out of twelve zoophilic sadomasochists had engaged in coprophilic acts whereas only one in twelve non-zoophilic sadomasochists had engaged in coprophilic cats. In fact, the zoophilic sadomasochists were more likely to engage in a wide range of sexual behaviours including spanking, gagging, biting, urophilia (urinating on or being urinated on for sexual pleasure), fisting, coprophilia, skin branding, and transvestism (i.e., cross-dressing). The authors concluded that zoophilic sadomasochists were more sexually experimental than the non-zoophilic sadomasochistic controls.

An earlier study on a much bigger sample of paraphiliacs also reported that zoophiles appear to engage in many paraphilic behaviours including coprophilia. In their survey of 561 non-incarcerated paraphiliacs seeking treatment, Dr Gene Abel and colleagues found that all of the 14 zoophiles in their sample reported more than one paraphilia and seven of them reported at least five other paraphilas including coprophilia, urophilia, pedophilia, exhibitionism, voyeurism, frotteurism, telephone scatophilia, transvestic fetishism, fetishism, sexual sadism, and/or sexual masochism.

There doesn’t appear to be any consensus as to the origins of these highly unusual paraphilias although (as with most paraphilic behaviour) operant and classical conditioning would appear to play a major role. The following example is a self-report that I found in an online discussion group:

“It all started when I was young. I hated white underwear for some reason and when I wore them I’d be turned on. Eventually it felt odd and good that I urinated in them. I wet my bed for days when I was a young boy and stopped when my parents found out about it. When I was young, I hated bowel movements. It felt gross and stuff. After discovering masturbation, I eased my bowel movements by masturbating. It felt good, and my bowel movements weren’t so gross. I don’t know how it happened but the two finally caught up to each other and I became accustomed to the smell when I masturbated. Everything escalated as time went on, I’ve been in this fetish for a while now – since I was 12 years old. I am 18 now”

The origins of the coprophilic behaviour certainly appear (in this case) to be as a result of both classical and operant conditioning. However, other people suggest different etiological factors may contribute in the development of coprophilia. For instance, in Canada, Dave Hingsburger published a case study of an institutionalized and mentally handicapped man who engaged in coprophilic acts approximately three times a week. It was argued that the cause of the coprophilia was the patient’s maladaptive response to a severely limited institutional environment rather than any behavioural conditioning.

Whatever the origins, it is evident that compared to many other paraphilic behaviours, there is a dearth of empirical and clinical data relating to the acquisition, development, and maintenance of coprophilia.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Abel, G. G., Becker, J. V., Cunningham-Rathner, J., Mittelman, M. S., & Rouleau, J. L. (1988). Multi- ple paraphilic diagnoses among sex offenders. Bulletin of the American Academy of Psychiatry and the Law, 16, 153–168.

Allen, C. (1969). A textbook of psychosexual disorders (2nd ed.). London: Oxford University Press.

Denson, R. (1982). Undinism: The fetishizaton of urine. Canadian Journal of Psychiatry, 27, 336–338.

Hallett, G. (2008). Hitler was a British agent. London: Progressive Books.

Hingsburger, D. (1989). Motives for coprophilia: Working with individuals who had been institutionalized with developmental handicaps. Journal of Sex Research, 26,139-140

Karpman, B. (1948). Coprophilia: A collective review. Psychoanalytic Review, 35, 253–272.

Karpman, B. (1949). A modern Gulliver: A study in coprophilia. Psychoanalytic Review, 36, 260-282.

Lake, C.R. (2008). Hypothesis: Grandiosity and guilt cause paranoia; Paranoid schizophrenia is a psychotic mood disorder; a review. Schizophrenia Bulletin, 34, 1151-1162.

McCary, J. L. (1967). Human sexuality. New York: Van Nostrand Reinhold.

Milner, J.S., Dopke, C.A. & Crouch, J.L.  (2008). Paraphilia not Otherwise Specified: Psychopathology and theory. In Laws, D.R. & O’Donohue, W.T. (Eds.), Sexual Deviance: Theory, Assessment and Treatment (pp.384-418). New York: Guildford Press.

Penix, T.M. (2008). Paraphilia not Otherwise Specified: Assessment and treatment. In Laws, D.R. & O’Donohue, W.T. (Eds.), Sexual Deviance: Theory, Assessment and Treatment (pp.419-438). New York: Guildford Press.

Sandnabba, N.K., Santtila, P. & Nordling, N. (1999). Sexual behavior and social adaptation among sadomasochistically-oriented males. Journal of Sex Research, 36, 273-282.

Sandnabba, N.K. Santtila, P., Nordling, N. Beetz, A.M., Alison, L. (2002). Characteristics of a sample of sadomasochistically-oriented males with recent experience of sexual contact with animals. Deviant Behavior, 23, 511-529.

Smith, R. S. (1976). Voyeurism: A review of the literature. Archives of Sexual Behavior, 5, 585–608.

Wise, T.N. & Goldberg, R.L. (1995). Escalation of a fetish: Coprophagia in a nonpsychotic adult of normal intelligence. Journal of Sex and Marital Therapy, 21, 272-275

Research in the gambling studies field has shown that erroneous perceptions can result from both types of misbelief outlined by McKay and Dennett (i.e., either through some kind of break in the normal functioning of the belief formation system, and in the normal course of that system’s operations). Despite the fact that the odds of almost all gambling activities are weighted strongly in favour of the gambling operator, gamblers – and particularly problem gamblers – continue to believe they can win money from gambling. This observation leads to the conclusion that gambling may be maintained by irrational or erroneous beliefs. For example, people overestimate the extent to which they can predict or influence gambling outcomes and tend to misjudge how much money they have won or lost. This hypothesis has been confirmed in numerous studies (including some of my own published studies) showing that people overestimate the degree of skill or control that can be exerted in chance activities.

Using the arguments put forward by McKay and Dennett (2009) to re-examine the empirical gambling literature on cognitive bias, it could perhaps be argued that many of the kinds of erroneous perceptions displayed by gamblers (e.g., hindsight biases, availability biases, confirmation biases, illusory correlations, representativeness biases, etc.) comprise ecologically rational decision-making strategies that inevitably operate when there are limitations of time and computational resources (i.e., the “take the best” heuristic). Furthermore, it could also be argued that the misbeliefs shown by some problem gamblers at the height of their disordered gambling may as Autralian psychologist Peter Butler describes as a “defense against depressive overwhelm”. Here, certain delusions shown by gamblers might be serving as plausible defensive functions.

Some research I carried out with Dr. Jonathan Parke (Salford University) and Dr Adrian Parke (Lincoln University) examined the role of positive thinking among gamblers. We noted the previous research in health and clinical settings showing that individuals often employ particular cognitive strategies in the face of adversity or while experiencing negative affect. Such health-related studies have found that cognitive experience is involved in compensating for a negative emotional state. Furthermore, self-aggrandizement, an exaggerated sense of optimism and over-estimating personal control, are found to be key responses to threatening information (such as being told the patient has a life-threatening illness). These observations have shown that despite some incongruence with reality, these misbeliefs are correlated with good (rather than poor) adjustment to the illness.

Despite the history of positive thinking styles in the health and clinical arena, there had not – until relatively recently – been any research on this area in relation to gambling behaviour. Therefore, we set out to determine whether (after gambling) gamblers compensate and reduce negative affect by identifying positive consequences from experiencing a loss. We identified nine types of ‘positive thinking’ experienced by gamblers (comparative thinking, prophylactic thinking, biased frequency thinking, responsibility avoidance, chasing validation, prioritization, resourcefulness, thoughtfulness, and fear reduction). Gamblers who were positive thinkers experienced significantly less guilt about losing than non-positive thinkers.

Here, the positive illusions displayed by gamblers are (following McKay and Dennett’s arguments) accruing benefit from misbelief directly not merely from the systems that produce it. However, unlike the positive illusions outlined by McKay and Dennett, we argued that in the case of gambling behaviour maintenance, this is one type of behaviour where positive illusions have a negative detrimental effect over time and that unlike most other areas of human behaviour, are maladaptive in this context.

Why gamblers should consistently demonstrate these biases and where they come from is not so clear. It is also unclear whether use of positive illusions depends on intrinsic factors (e.g., psychological mood state) and/or extrinsic factors (e.g., gambling history). It has been suggested that persistent gambling behaviour is thought to be the result of people’s overconfidence in their ability to win money. While research regarding positive illusions in gambling may be lacking, research has found that gambling behaviour is facilitated when players believe they have control over the event and when they feel that they are “nearly winning” even in the event of a losing outcome. It should also be noted that the fundamental difference between heuristics and positive illusions is that heuristics operate to remove doubt, whereas positive illusions operate to remove negative affect created by the adverse consequences of gambling. By overestimating benefits and reducing guilt, positive illusions disrupt the naturally occurring contingencies of reinforcement that might otherwise prevent excessive gambling.

While reduction of negative affect may be perceived as positive in many other contexts, it is maladaptive in gambling behaviour (at least on an individual level). However, it also appears that such misbeliefs may have continued to evolve among gamblers despite individual detriment. This is because many of the same types of positive illusions appear to be displayed by gamblers consistently over time.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading 

Butler, P. V. (2000). Reverse Othello syndrome subsequent to traumatic brain injury.  Psychiatry: Interpersonal & Biological Processes, 63, 85-92.

Griffiths, M.D. (1994). The role of cognitive bias and skill in fruit machine gambling. British Journal of Psychology, 85, 351-369.

Langer, E. J. (1975). The illusion of control. Journal of Personality and Social Psychology, 32, 311-328.

McKay, R.T. & Dennett, D.C. (2009). The evolution of misbelief. Behavioral and Brain Sciences, 32, 493-561.

Parke, J. & Griffiths, M.D. (2004). Gambling addiction and the evolution of the ‘near miss’. Addiction Theory and Research, 12, 407-411.

Parke, J., Griffiths, M.D. & Parke, A. (2007). Positive thinking among slot machine gamblers: A case of maladaptive coping? International Journal of Mental Health and Addiction, 5, 39-52.

Taylor, S. E. (1989). Positive illusions: Creative self-deception and the healthy mind. New York: Basic Books.

Wagenaar, W. A. (1988). Paradoxes in Gambling Behaviour. London: Erlbaum.

When I started to research this a little further, I was surprised to discover that there are many reports in the medical literature dating back almost 100 years of the consequences of excessive carrot eating. The most commonly reported consequence is that excessive carrot eating can cause people’s skin pigmentation to turn yellow (a condition that has since been given the name hypercarotenemia). In 1975, there was an infamous case that received widespread news coverage concerning the death of a 48-year old man who drank excessive amounts of carrot juice. The coroner actually attributed the man’s death as addiction to carrot juice although Dr Ivan Sharman (writing in an article in a 1985 issue of the British Medical Journal on hypercarotenemia) speculated that the person’s addiction to carrots may have reduced the patient’s intake of more nourishing food. Cases of hypercarotenemia have also been reported amongst people with anorexia, hypothyroidism, and Down’s Syndrome.

The 1992 BJA paper described three cases (one male and two females) who the authors claimed had developed a psychological dependence on carrots. The dependence was – in part – caused by the ‘active ingredients’ (including carotine) found in carrots. When unable to eat carrots, these people displayed symptoms of irritability and nervousness, and were said to have an inability to simply discontinue. All three people were cigarette smokers and the two women described their dependence on carrots as stronger than that of nicotine (whereas the man described it as slightly weaker). The man was eating “five bunches” of carrots daily and had – somewhat ironically – started eating carrots as a way of trying to reduce the amount of cigarettes that he smoked. When he gave up carrots, he resumed smoking. One of the women ate a kilogram of raw carrots a day, and was treated for ‘neurological disturbance’. The other woman – pregnant with her first child – started eating large quantities of carrots. She managed to stop eating carrots excessively for 15 years after the baby was born. However, following a stomach upset she relapsed. According to the authors, there was a happy outcome when the woman switched to radishes and developed a diet totally free of carrots!

In 1996, another paper was published in the Australian and New Zealand Journal of Psychiatry by Dr. Robert Kaplan (a consultant psychiatrist at the Liaison Clinic in Wollongong, Australia). The paper concerned the case of a 49-year-old female compulsive carrot eater who after a period of depression (caused by the breakdown of her marriage) started to eat 2-3kg of carrots every day, and lost interest in eating any other food. As in the cases outlined above, she was also a heavy smoker. As Dr Kaplan wrote:

“She rapidly lost interest in eating any other foods. Attempts to resist the craving were useless and she would get out of bed at night to eat more carrots. Her activities began to revolve around this activity, particularly the almost- daily visits to the supermarket. She became an expert in assessing the carrots, selecting them on size and shape: features which would determine the woodiness and succulence when eaten. As she put it: ‘I just wanted to eat a nice juicy carrot and couldn’t stop munching after that’…[She then developed a] noticeable orange/yellow discolouration of her face and hands. She explained that the carrot eating had overtaken her life and she had been too embarrassed to tell me about it at earlier visits. However, the skin discoloration was now quite visible and she felt self-conscious in public. In an attempt to overcome the problem she had stayed with her parents for several weeks, where they had encouraged her to eat normal meals. However, the craving continued and she became concerned about her appearance and the loss of control” (p.699).

The carrot eating continued and she was unable to stop eating carrots (she couldn’t last more than half a day before she gave in to the craving. Any attempt to stop eating carrots led to intense withdrawal symptoms (including anxiety, restlessness, shaking, craving, irritability, and insomnia). During a hysterectomy, the surgeon discovered that the woman’s internal organs were a bright yellow colour. Dr. Kaplan then noted:

“Losing her appetite, she stopped smoking cigarettes and eating carrots. The first few days lead to intense cravings for both substances, which settled, followed by cigarette cravings for a few more weeks. She felt that the postoperative distress and nicotine withdrawal symptoms had a combined effect which helped her overcome her carrot craving. Within 4 weeks, she felt she had overcome the carrot addiction, with cessation of both psychological and physical symptoms” (p.699).

The woman maintained her cessation of carrot eating although still occasionally craved cigarettes. Dr Kaplan reported that the thought of eating carrots now repulsed her. Interestingly, the woman believed that she couldn’t have stopped eating carrots without the discomfort produced by the nicotine withdrawal. It was concluded that compulsive carrot eating is a rare condition and that the basis for the addiction is most likely beta carotene (found in carrots). Although the woman was administered sertraline for her depression, it had no effect on the amount of carrots that she ate.

The idea that food can be addictive is not new and there are certainly reports of specific foodstuffs being addictive (chocolate perhaps being an obvious case in point). However, based on these few published case studies (particularly the one reported by Kaplan), it would appear that in extreme and very unusual circumstances, that carrots may indeed be addictive to some people.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

al-Jubouri, M.A., Coombes, E.J., Young, R.M. & McLaughlin, N.P. (1994). Xanthoderma: an unusual presentation of hypothyroidism. Journal of Clinical Pathology, 47, 850-851.

černý, L. & černý, K. (1992). Can carrots be addictive? An extraordinary form of drug dependence. British Journal of Addiction, 87, 1195-1197.

Corwin, R.L. & Grigson, P.S. (2009). Overview – food addiction: Fact or fiction? Journal of Nutrition, 139: 617–619.

Hess, A.F. & Myers, V.C. (1919) Carotenaemia: A new clinical picture. Journal of the American Medical Association, 73, 1743.

Kaplan, R. (1996), Carrot addiction. Australian and New Zealand Journal of Psychiatry, 30, 698-700.

Leitner, Z.A., Moore, T., & Sharman, I.M. (1975). Fatal self-medication with retinol and carrot juice. Proceedings of the Nutrition Society, 34, 44A.

Pelchat, M.L. (2009). Food addiction in humans. Journal of Nutrition, 139, 620-622.

Schoenfeld, Y., Shaklai, M., Ben-Baruch, N., Hirschorn, M. & Pinkhaus, J. (1982). Neutropenia induced by hypercarotenemia. The Lancet, i, 1245.

Sharman, I.M. (1985). Hypercarotenaemia. British Medical Journal, 290, 95-96.

Sherman, P., Leslie, K., Goldberg, E., Rybczynski, J. & St-Louis, P. (1994). Hypercarotenemia and transaminitis in female adolescents with eating disorders: A prospective, controlled study. Journal of Adolescent Health, 15, 205-209.

Storm W. (1990). Hypercarotenemia in children with Down’s syndrome. Journal of Mental Deficiency Research, 34, 283-286.

Back in the 1990s, I appeared on a number of television programmes along with people like Britain’s most famous comper at the time called “Rita the competer” who had won prizes worth hundreds of thousands of pounds including multiple houses, cars, holidays, and electrical goods. Most of the compers that I met at that time – all women I have to add – spent most (if not all) of their spare time cutting out and filling in competitions from magazines, newspapers and newsletters.

More recently, compers have gone digital and is inextricably linked to the rise of social media like Facebook and Twitter. The comping community has many ‘comping’ magazines, newsletters and websites (for instance sites such as Compers Corner, Crazy Compers, Compers Weekly, and Just Comps). There are also loads of blog sites updating compers of all the latest offline and (now mostly) online competitions. Today’s compers appear to spend hours on the main social media websites entering competitions run directly by commercial operators. There also appears to be more men becoming compers which may be due to it becoming an increasingly online activity (I say “appear” because I know of no empirical research that has ever been carried out on the ‘comping’ community). Now compers can enter dozens (even hundreds if you click on some of the comping sites listed above) of competitions every week without spending any of their own money on stamps and envelopes.

So why are there so many competitons out there? In order to remain competitive, commercial retailers need to make use of the wide variety “tools” at their disposal within the marketing management toolkit (e.g., sales promotions, advertising). However, there is growing awareness that non-price-based promotions (e.g., consumer competitions) add value for the consumer while meeting a range of marketing communications objectives (which is where the world of comping has originated).

A recent paper by Philip DesAutels and colleagues at the Luleå University of Technology (Sweden) noted that marketing goals for contests may be external to the contest (e.g., increasing product, service or brand awareness), or they may be internal to a contest (e.g., directly increasing product adoption or sales). More commonly, their goals are a combination of the two. Their research into sales promotion effectiveness introduces two measures of contest performance: in-contest engagement and post-contest product interest. They call on the research community to do further work into effective ways to measure and assess these two goals as they believe they “will serve as an immeasurable aid to practice and research”. They also note that activities that are intrinsically motivating are undertaken because they are interesting, enjoyable or satisfying. The act of doing them is the reward. Activities that are extrinsically motivating are undertaken to achieve rewards that are separate and distinct from the activity itself.

Earlier today I appeared on BBC Breakfast’s television show talking about the psychology of ‘compers’ and to what extent compers are like gamblers and to whether it is possible for compers to become ‘addicted to their hobby. The nearest comparison to comping in the gambling world – at least in terms of motivation to carry out the activity – is lottery gambling. The main motivating factor in both comping and playing the lottery is the chance to potentially win a large (often life changing or life enhancing) prize for very little financial outlay. It’s as simple as that. However, there are other similarities including the activity being fun, and the social interaction with friends who engage in like-minded activities.

In relation to ‘comping addiction’ I have never come across a case either professionally or personally that fulfill my criteria for addiction. However, my view as with any behaviour that offers the potential for constant rewards and reinforcement, it is theoretically possible. I’ve certainly met people (admittedly in the confines of a television studio) who claimed that ‘comping’ had taken over their life and that it was causing conflict in some aspect of their life (usually relationship conflict where husbands complained that their wives were spending all their leisure time doing competitions).

However, I really don’t think any of the excessive compers I have met were addicted to the behaviour because the activity was life affirming and life enhancing. As I never tire of telling my students or the media, the key difference between a healthy enthusiasm and an addiction is that healthy enthusiasms add to life whereas addictions take away from it. On that criteria alone, the chances of meeting someone addicted to comping is remote.

Finally, it is worth noting that as long ago as 1991, Ward and Hill wrote that “virtually no work has been done in advertising on the psychology of promotional games. Thus, much opportunity exists”. The 2011 paper by Philip DesAutels and colleagues said it “is therefore surprising that in the 20 years since the publication of Ward and Hill’s article, so little research has been undertaken to inform the theory and practice of promotional competitions and contests”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

DesAutels, P., Berthon, P. & Salehi-Sangari, E. (2011). Rising to the challenge: A model of contest performance. Journal of Financial Services Marketing, 16, 263–274

Griffiths, M.D. (1997). Instant-win promotions: Part of the gambling environment? Education and Health, 15, 62-63.

Griffiths, M.D. (2003). Instant-win products and prize draws: Are these forms of gambling? Journal of Gambling Issues, 9. Located at: http://www.camh.net/egambling/issue9/opinion/griffiths/.

Griffiths, M.D.  (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M.D. & Wood, R.T.A. (2001). The psychology of lottery gambling. International Gambling Studies, 1, 27-44.

Ward, J.C. and Hill, R.P. (1991) Designing effective promotional games: Opportunities and problems. Journal of Advertising, 20(3), 69-81.

In the United States, the prevalence of past year adolescent gambling in the only national study was 67% with a past year problem gambling rate of 1.3%. However, state-by-state across more than 20 studies show there are large variations ranging from 20% to 86% (past year adolescent gambling prevalence rates) and 0.9–5.7% (past year adolescent problem gambling prevalence rates). In Canada, there has been no national study, only provincial surveys. These have shown a past year adolescent gambling prevalence of 24–90% and a past year adolescent problem gambling rate of 2.2–8.1%.

In Europe, there have been relatively few studies of adolescent gambling and the quality is variable in terms of sample size, representativeness, and quality of data. Adolescent gambling prevalence rates have been reported for a number of countries. These include Belgium (42% lifetime prevalence), Estonia (75% lifetime prevalence), Finland (52% past year prevalence), Germany (62% past year prevalence), Great Britain (19–70% past year prevalence), Iceland (57–70% past year prevalence), Norway (74–82% past year prevalence), Romania (82% lifetime prevalence), Slovakia (27.5% lifetime prevalence), and Sweden (76% past year prevalence). Adolescent problem gambling prevalence rates have been reported for a number of countries. These include Estonia (3.4% lifetime prevalence), Finland (2.3% past year prevalence), Germany (3% past year prevalence), Great Britain (2–5.6% past year prevalence), Iceland (1.9–3.0% past year prevalence), Italy (6% past year prevalence), Norway (1.8–3.2% past year prevalence), Romania (7% lifetime prevalence), Spain (0.8%–4.6% past year prevalence), and Sweden (0.9% past year prevalence).

In Australia, there has also been no national study, only territory surveys. These have shown a past year adolescent problem gambling rate of 41–89% and a past year adolescent problem gambling rate of 1.0–4.4%. In New Zealand, the two national surveys have shown a past year adolescent gambling rate of 65–68% and past year adolescent gambling problem gambling prevalence rates of 3.8–13%.

From these reviews, a number of conclusions have been made. First, from a methodological perspective, the reviews show that school-based surveys and telephone surveys were the primary modalities used to collect data in adolescent prevalence surveys. Second, a methodological trend of increasing sample sizes over time was noted. Early adolescent gambling surveys in the late 1980s and early 1990s tended to include samples of only a few hundred whereas most recent surveys are much bigger. For instance, the five national prevalence surveys in Great Britain have typically had sample sizes of approximately 8000 or more. Third, it was noted that the most widely used problem gambling instruments are derived from adult problem gambling screens and may not be suited to assessing gambling-related problems in younger people. However, pending a better-validated problem gambling instrument for adolescents, these instruments are likely to continue to be viewed as the best approximations for the measurement of problem gambling among adolescents.

The reviews have also made a number of other generalizations. Male adolescents are more likely than female adolescents to gamble, and more likely to experience problems, a finding that is well established. However, there is no evidence that problem gambling among females indicates a more serious problem. It also appears that, while adolescents from certain ethnic groups are less likely to gamble than other adolescents (e.g., Native American and African American youth in North America, non-Francophone youth in Quebec, indigenous youth in Australia, and Pacific Island youth in New Zealand), they are more likely to gamble regularly when they do gamble and to experience problems. However, there may be other confounding variables such as socioeconomic status.

There are also other clear demographic patterns. For example, the most popular youth gambling activities tend to be private, peer-related activities such as card games and betting on sports. Older youth are more likely to engage in accessible forms of age-restricted gambling, such as lotteries. The one notable exception is in Great Britain where slot machines are legally available for adolescents to gamble on at seaside arcades and family leisure centers. Unlike most other countries, Great Britain’s adolescent problem gamblers are most likely to be experiencing gambling problems associated with slot machines. Other common demographic characteristics are that youth problem gamblers are more likely to start gambling at a younger age and to have parents who gamble.

Other research has shown that young problem gamblers are also more likely to have begun gambling at an early age, have had a big win early on in their playing career, and to be from a lower social class. In addition to the risk factors based on personal characteristics, the social and physical environment in which young people gamble and the gambling activity also play a part. Research has indicated that the most problematic and addictive gambling activities to be those (such as slot machines) that involve high event frequencies, short interval between stake and payout, near miss opportunities, a combination of very high prizes and/or frequent winning of small prizes, and suspension of judgment.

Like other potentially addictive behaviors, problem gambling in adolescence causes the individual to engage in negative behaviours. In Great Britain, research has indicated these negative behaviours include truanting in order to play the slot machines, stealing to fund slot machine playing, getting into trouble with teachers and/or parents over their machine playing, borrowing or the using of lunch money to play slot machines, poor schoolwork, and in some cases, aggressive behavior. One study demonstrated that around 4% of all juvenile crime in one English city was gambling-related based on over 1850 arrests in a one-year period.

Furthermore, teenage problem gamblers also appear to display bona fide signs of addiction including withdrawal effects, tolerance salience, mood modification, conflict, and relapse. Some young people gamble as a means of coping with everyday stresses and problems (avoidance) and as their gambling becomes more problematic so their problems, such as debt, increase and consequently their need to gamble also increases. This therefore creates a vicious circle whereby gambling behavior is experienced as both a problem and as a strategy for dealing with problems. It has also be noted that adolescent gambling is often part of a lifestyle that includes increased prevalence in many risky behaviors (such as smoking cigarettes, drinking alcohol, and taking illicit drugs).

Adolescent gambling, and more specifically adolescent problem gambling, is a cause for concern with a small but significant minority of adolescents having a severe gambling problem. Furthermore, the prevalence of problem gambling in adolescents tends to be approximately three to five times higher than that in adults (depending upon the jurisdiction and the opportunities for adolescents to gamble). This suggests that many adolescents stop gambling when they reach adulthood, although there have been no longitudinal studies to date. Retrospective reports in the literature suggest that many adolescent gamblers ‘mature out’ of gambling and that there are some events in the lives’ of older adolescent that may be triggers in spontaneous remission (such as getting a job, getting married, and birth of a child). However, these are anecdotal and further research is needed to help identify protective factors for problem gambling.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

With additional input from: Dr Rachel Volberg (Gemini Research, USA), Dr Rina Gupta (McGill University, Canada), Dr Paul Delfabbro (University of Adelaide, Australia), and Dr Daniel Olason (University of Iceland, Iceland)

Further reading

Griffiths, M.D. (2002). Gambling and Gaming Addictions in Adolescence. Leicester: British Psychological Society/Blackwells.

Griffiths, M.D. (2008). Adolescent gambling in Great Britain. Education Today: Quarterly Journal of the College of Teachers. 58(1), 7-11.

Griffiths, M.D. (2011). Adolescent gambling. In B. Bradford Brown & Mitch Prinstein (Eds.), Encyclopedia of Adolescence (Volume 3). pp.11-20. San Diego: Academic Press.

Griffiths, M.D. & Parke, J. (2010). Adolescent gambling on the Internet: A review. International Journal of Adolescent Medicine and Health, 22, 59-75.

Griffiths, M.D., Parke, J. & Derevensky, J. (2011). Online gambling among youth: Cause for concern? In J.L. Derevensky, D.T.L. Shek & J. Merrick (Eds.), Youth Gambling: The Hidden Addiction, pp. 125-143. Berlin: DeGruyter.

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2010). The convergence of gambling and digital media: Implications for gambling in young people. Journal of Gambling Studies, 26, 175-187.

Meyer, G., Hayer, T. & Griffiths, M.D. (2009). Problem Gaming in Europe: Challenges, Prevention, and Interventions. New York: Springer.

Volberg, R., Gupta, R., Griffiths, M.D., Olason, D. & Delfabbro, P.H. (2010). An international perspective on youth gambling prevalence studies. International Journal of Adolescent Medicine and Health, 22, 3-38.

Dr Alfred Kinsey’s surveys of sexual behaviour of males and females in the late 1940s and early 1950s research specifically mentioned women using enemas as a masturbatory aid but no such practice was reported by males. Although Kinsey’s research provided evidence that klismaphilia was engaged in by women, as with most paraphilias, it is typically males who are more likely to be klismaphiliacs. Published research on klismaphiliacs is rare and it is thought that most klismaphiliacs keep their engagement in this activity very secret.

The little research into klismaphilia suggests that the act of receiving enemas can cause intense stimulation and produce pleasurable sensations (e.g., gaining pleasure from a large, water distended belly or the feeling of internal pressure). Enemas cause mechanical distension of rectum that then cause stimulation of nerve endings supplying the pelvic organs (i.e., stimulating the rectal stretch receptors). It has also been reported that drugs that are administered rectally (including aqueous and alcoholic solutions) are absorbed very rapidly and has a “mainlining effect” similar to that of intravenous drug injection.

Typically, klismaphiliacs retrospectively report discovering these very particular sexual desires after being given enemas sometime in their childhood. Published case studies suggest that klismaphilia ost likely arises in those children who received them as children by a loving and affectionate mother. This association of loving attention with anal stimulation may eroticize the experience for some people so that as adults they may manifest a need to receive an enema as a substitute for or necessary prerequisite to genital intercourse.

Following the publication of her two case studies, Dr Joanne Danko published a study in the mid-1970s on 15 klismaphiliacs. Based on these limited data, she concluded that klismaphiliacs comprised one of three groups she labeled Type A, Type B and Type C.

• Type A: These individuals were unhappy, believed their klismaphilic behaviour as abnormal, and kept the behaviour compartmentalized. The behaviour originated in childhood and the enemas were usually self-administered. Some of the cases in this group also engaged in other paraphilic behaviour (e.g., fetishism masochism, coprophilia).
• Type B: These individuals were similar to Type A individuals, but accepted the condition and were more likely to engage in klismaphilia with their sexual partner.
• Type C: These individuals engaged in multiple paraphilic behaviours with other similar like-mined individuals, and their klismaphilia was integrated with a range of other praphilic behaviours (e.g., transvestism, masochism).

Back in 1991, the American sexologist Dr William Arndt placed advertisements in sex magazines to recruit klismaphiliacs. He managed to survey 22 individuals (all males except for one female) and aged 25 to 54 years. Most were homosexual (80%; the other 20% were bisexual) although nearly two-thirds were married (or had been married). They typically engaged in enema use twice a week and half of the klismaphiliacs reported the enemas were self-administered. The remainder gave and/or received enemas from their sexual partner. Just over one-third of the sample (40%) had other paraphilic interests that typically revolved around sexual masochism (e.g., being spanked).

In a 1982 American Journal of Psychotherapy paper, Jeremy Agnew (1982) provided a physiological perspective on klismaphilia concentrating on the ritualization of insertion, filling, and expulsion components. He compared the physiological similarities between rectal stimulation and vaginal intercourse and said that the behaviour was reinforcing. This observation – taken together with the work of Dr Danko – suggests that much of the klismaphiliac’s behaviour is maintained by both classical and operant conditioning. In a later 2000 paper, Agnew also noted that some individuals receive such extreme pleasure from the practice that they reach orgasm. He also links klismaphilia with sadomasochistic activities.

Accidental rectal trauma and the lodging of foreign bodies in the gastrointestinal tract have been widely reported in the medical literature. Arguably the most notorious case of klismaphilia is that reported by Dr Peter Stephens and Dr Mark Taff in the American Journal of American Pathology. They wrote about a young man who turned up at the hospital complaining of rectal pain. After an examination by the doctor, it became apparent that there was a stony hard mass lodged in the man’s rectum. Upon further questioning, the patient revealed that four hours earlier, he and his boyfriend had been “fooling around” and that after stirring a batch of concrete mix, the patient had laid on his back with his feet against the wall at a 45 degree angle while his boyfriend poured the mixture through a funnel into his rectum. The concrete had set and was eventually removed. On removal, a ping-pong ball was also found. The reason a ping-pong ball was also found in the rectum was because klismaphiliacs use the ball as a plug to promote retention and increase stimulation. The use of such a device suggests the person was an experienced klismaphiliac.  As Dr Anil Hernandas and colleagues conclude “as the exploration of anal eroticism increases in popularity, more and more cases of complications as a direct result of their abuse are likely to be encountered”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Agnew, J. (1982). Klismaphilia: A physiological perspective. American Journal of Psychotherapy, 36, 554–566.

Agnew, J. (2000). Klismaphilia. Venereology, 13(2), 75-79

Arndt, W.B. (1991). Gender disorders and the paraphilias. Madison, CT: International Universities Press.

Boglioli, L.R., Taff, M.L., Stephens, P.J. & Money, J. (1991). A case of autoerotic asphyxia associated with multiplex paraphilia. American Journal of Forensic Medicine and Pathology, 12, 64– 73.

Denko, J.D. (1973). Klismaphilia: Enema as a sexual preference. American Journal of Psychotherapy, 27, 232–250.

Denko, J.D. (1976). Klismaphilia: Amplification of the erotic enema deviance. American Journal of Psychotherapy, 30, 236–255.

Hemandas, A.H., Muller, G.W. & Ahmed, I. (2005). Rectal Impaction With Epoxy Resin: A Case Report. Journal of Gastrointestinal Surgery, 9, 747–749.

Kinsey, A. C., Pomeroy, W. B., Martin, C.E., Gebhard, P.H. (1953). Sexual Behavior in the Human Female. Philadelphia, PA: W.B. Saunders Company.

Kinsey, A. C., Pomeroy, W. B., Martin, C.E., (1948). Sexual Behavior in the Human Male. Philadelphia, PA: W.B. Saunders Company.

Stephens, P. & Taff, M. (1987). Rectal impaction following enema with a concrete mix. American Journal of Forensic Medicine and Pathology, 8, 179–182

“You recently decided to gamble $120 on your favourite form of gambling. You initially won $60 but then following a bad run of luck, lost $100. Feeling tired, you decided to leave and return home”

When participants in the study were given this scenario above, and asked “How much did you spend on gambling?” they made a number of different interpretations. There are four basic interpretations that ‘spend’ could relate to:

• Stake: This refers to the amount staked (i.e. the amount bet on an individual event, such as a football match, a fixed odds betting terminal or a lottery ticket).
• Outlay: This refers to the sum of multiple bets risked during a whole gambling session.
• Turnover: This refers to the total amount gambled, including any re-invested winnings.
• Net expenditure: This refers to the amount gambled minus any winnings.

In this particular study, approximately two-thirds of the participants (64%), answered $40 (i.e., net expenditure) in the scenario above [i.e., $120-($120+$60-$100)]. Around one-sixth of the participants (17%) answered $120 (i.e., stake). A small number of participants answered $160. Here the participants reasoned the spend was equal to $120+$100-$60. Alternatively some answered $100 that equated to the amount lost. Finally, a very small number of participants (n=5) answered $180 (i.e., turnover), where the participants reasoned that spend was equal to investment plus winnings.

There are also issues surrounding what constitutes an individual session (especially if the person gambling goes to the toilet or has a snack or drink between or during a gambling episode). What this simple study shows is that questions relating to expenditure need to be very precise. Blaszczynski and his colleagues argued that the most relevant estimate of gambling expenditure is net expenditure, as it reflects the actual amount of money the gambler has gambled, and also represents the true cost of gambling to the individual. In the 2007 British Gambling Prevalence Survey (BGPS), participants who had spent money on gambling in the past seven days were first asked for each activity that they had gambled on. “Overall, in the last seven days did you win or lose money?” To this particular question the gamblers could either answer that they lost, won, broke even, or were still awaiting the result. If gamblers had lost money they were asked how much, and were asked to tick one of six boxes indicating the total amount lost. Similarly, if gamblers had won money they were asked how much, and could tick one of six boxes indicating the total amount won. They were also asked to what extent the previous week’s gambling activity had been typical.

The results relating to net expenditure were interesting and perhaps somewhat predictable based on what has been reported in previous literature. Gamblers appeared to over-estimate how much they had won in the previous week, meaning that net expenditure was ‘positive’ on many of the gambling activities (i.e. on these activities, gamblers claimed to have won more than they had lost). A similar finding was also reported in the previous [1999] BGPS. Given that all sectors of the gaming industry make ‘considerable profits’, the results in the BGPS study clearly show that many gamblers do not appear to be making a realistic assessment of their previous week’s spending.

However, this does not necessarily mean that they are ‘lying’, as there is a lot of evidence that gamblers over-estimate winnings and under-estimate losses, due to cognitive biases and heuristics like the ‘fixation on absolute frequency bias’ (using absolute rather than relative frequency as measure of success), concrete information bias (when concrete information such as that based on vivid memories or conspicuous incidents dominates abstract information such as computations or statistical data), and/or flexible attributions (the tendency to attribute successes to one’s own skill and failures to other influences). In short, winning experiences tend to be recalled far more easily than losses (unless the losses are very substantial and have a major detrimental effect on the day-to-day functioning of the individual).

Remembering wins and discounting losses is a consistent finding in the gambling literature. This is more likely to occur on those gambling activities that are played several days a week, rather than those activities that are engaged in once a week such as the National Lottery Draw and the football pools. It is in these latter activities that participants are more likely to have accurate recall of wins and losses, as the weekly outlay is usually identical every week (e.g. buying two lottery tickets every week or being part of a lottery syndicate). The results in the 2007 BGPS do indeed seem to indicate this is the case, with activities such as the National Lottery Draw, and the football pools, reporting weekly net losses.

Furthermore, there are other more general effects (like social desirability) that may be skewing the results in a more socially positive direction. There is also the general observation that people tend to overestimate positive outcomes and underestimate negative ones that has been applied to the psychology of gambling. Most of the positive net expenditures were fairly modest, but on those gambling activities where skill has the potential to be used, the net expenditures were much greater (e.g. online poker as part of online gambling, blackjack as part of casino table games). The results showing that the smaller the number of participants gambling on the particular activity, the greater the overall net win claimed, highlights the fact that individual variability was likely to be more pronounced among lower numbers of participants. It is also likely that some of the activities do indeed include gamblers who genuinely win more than they lose (online poker being a good example). However, the number of people doing this regularly is likely to be relatively small, as there are always more losers than winners in such activities.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Blaszczynski, A., Dumlao, V. & Lange, M. (1997). How much do you spend gambling? Ambiguities in survey question items. Journal of Gambling Studies, 13, 237-252.

Gilovich, T. (1983). Biased evaluation and persistence in gambling. Journal of Personality and Social Psychology, 44, 1110-1126.

Griffiths, M.D. (1994). The role of cognitive bias and skill in fruit machine gambling. British Journal of Psychology, 85, 351-369.

Griffiths, M.D. & Wood, R.T.A. (2001). The psychology of lottery gambling. International Gambling Studies, 1, 27-44.

Wagenaar, W. (1988). Paradoxes of Gambling Behaviour. Hove: Lawrence Erlbaum Associates.

Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M.D., Constantine, R. & Pigott, S. (2007). The British Gambling Prevalence Survey 2007. London: The Stationery Office.

At its simplest level, BDD is a distressing, handicapping, and/or impairing preoccupation with an imagined or slight defect in body appearance that the sufferer perceives to be ugly, unattractive, and/or deformed (hence the recent upsurge in relation to those with an insistent desire for plastic surgery). BDD sufferers can think about their perceived defect for hours and hours every day. Other BDD sufferers may indeed have a minor physical abnormality, but the concern attached to it is regarded as grossly excessive. There are hundreds of published papers on BDD but most of this article is based on the writings and reviews of Dr Katharine Phillips (Professor of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, USA) and the British psychiatrist Dr David Veale (The Priory Hospital North London).

People with BDD have been written about for more than 100 years and there has been a large increase in research into BDD over the last two decades. Like pathological gambling, the criteria for BDD changed quite radically between the publication of the American Psychiatric Association’s DSM-III (1980), and DSM-IV (1994). Until relatively recently, BDD used to be called ‘’dysmorphophobia’. In the DSM-III, BDD didn’t have any specified diagnostic criteria and was only mentioned as an example of an atypical somatoform disorder. In the revise edition of the DSM-III (1987), BDD became a separate disorder in the somatoform section. Subtle changes were then made to the DSM-IV criteria.

Arguably the most notable change was that the distinction between ‘delusional’ and ‘non-delusional’ BDD was diminished due to empirical evidence showing that the delusional and non-delusional variants of BDD may be variants of the same disorder (it should also be noted that in the World Health Organization’s International Classification Diseases (ICD-10), BDD is classified as a type of hypochondriacal disorder along with hypochondriasis, in the somatoform section). There is frequent comorbidity in BDD (e.g., social phobia, depression, suicidal ideation, and obsessive-compulsive disorder). In fact, almost all BDD sufferers engage in at least one compulsive behaviour such as compulsive checking of mirrors, excessive grooming and make-up application, excessive exercise, repeatedly asking other people how they look, compulsive buying of beauty products, and persistent seeking of cosmetic surgery. These behaviours can become potentially all encompassing and consuming, and like many addictive behaviours become unpleasurable and typically difficult to control or resist. The current DSM-IV diagnostic criteria for body dysmorphic disorder are that there is:

• Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern in markedly excessive;
• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
• The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)

Dr David Veale notes that among BDD sufferers, any body part may be the preoccupying focus. However, research has indicated that most BDDs involve skin, hair, or facial features (e.g., eyes, nose, lips) that the sufferer feels is flawed (e.g., acne), out of proportion and/or asymmetric. Research has also shown that the pre-occupying focus can change over time. Dr Veale speculates that this changing focus may explain why some people are never happy after cosmetic surgery procedures. Sufferers may repeatedly examine the ‘‘defect’’ that for some may become obsessive and/or compulsive.

A couple of empirical studies have reported the prevalence of BDD as 0.7% in the general population. The prevalence rate among other specific groups – such as adolescents and young adults – tend to be a little higher, and among some groups it is significantly higher. For instance, much higher prevalence rates of BDD have been reported among people wanting plastic surgery (5%) and among dermatology patients (12%).

Dr Veale notes there are very limited data on the risk factors associated with the development of BDD. Furthermore, those factors that have been associated with BDD may not be unique or specific to BDD (for instance, risk factors such as poor peer relationships, social isolation, lack of support in the family, and/or sexual abus). Risk factors identified in BDD include:

• Genetic predispositions;
• Shyness, perfectionism, or an anxious temperament;
• Childhood adversity (e.g., teasing or bullying about appearance)
• A history of dermatological or other as an adolescent (e.g., acne) that has since been resolved.
• Being more aesthetically sensitive than average
• Greater aesthetic perceptual skills, manifested in their education or training in art and design.

Although there are various worldwide case studies, most published studies on BDD comprise people from Westernized societies. Dr Katharine Phillips and her colleagues claim there are no studies that have directly compared BDD’s clinical features across different countries or cultures but concluded that BDD studies from around highlighted there were more similarities than differences. Dr Phillips says that men and women had many similarities in these studies (demographic and clinical characteristics). She has also reported that both male and female BDD sufferers are equally likely to seek and receive dermatological and cosmetic treatment.

Dr Veale claims that although there are broad similarities between the genders there are some gender differences. For instance, men with BDD show a greater preoccupation with their genitals, and women with BDD are more likely to have a co-morbid eating disorder. Perhaps somewhat predictably, female BDD sufferers have a greater preoccupation with weight, hips, breasts, legs, and excessive body hair. They are also more likely than BDD males to conceal perceived defects with make-up, to check mirrors, and to pick at their skin. Male BDD sufferers have a greater preoccupation with muscle dysmorphia, and thinning hair. Compared t females, BDD males are more likely to be single, and have a substance-related disorder.

The most recent review by Dr Phillips and her colleagues concluded that: “Much more research is needed on all aspects of BDD. Advances in knowledge will likely lead to future refinements of this disorder’s diagnostic criteria and an increased understanding of the relationship between BDD’s delusional and non-delusional forms as well as BDD’s relationship to other psychiatric disorders”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Didie, E.R., Kuniega-Pietrzak, T., Phillips, K.A. (2010). Body image in patients with body dysmorphic disorder: evaluations of and investment in appearance, health/illness, and fitness. Body Image, 7, 66–69.

Kelly, M.M., Walters, C. & Phillips, K.A. (2010). Social anxiety and its relationship to functional impairment in body dysmorphic disorder. Behavor Therapy, 41, 143-153.

Mancuso, S., Knoesen, N. & Castle, D.J. (2010). Delusional vs nondelusional body dysmorphic disorder. Comprehensive Psychiatry, 51, 177-182.

Phillips, K.A. (2005). The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press.

Phillips, K.A. (2009). Understanding Body Dysmorphic Disorder: An Essential Guide. New York: Oxford University Press.

Phillips K.A. & Diaz, S.F. (1997). Gender differences in body dysmorphic disorder. Journal of Nervous and Mental Diseases, 185, 570–7.

Phillips, K.A., Wilhelm, S., Koran, L.M., Didie, E.R., Fallon, B.A., Jamie Feusner, J. & Stein, D.J. (2010). Body Dysmorphic Disorder: Some key issues for DSM-V. Depression and Anxiety, 27, 573-59.

Phillips, K.A., Menard, W. & Fay C. (2006). Gender similarities and differences in 200 individuals with body dysmorphic disorder. Comprehensive Psychiatry, 47, 77–87.

Phillips, K.A., Didie, E.R., Menard, W., et al. (2006). Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Research, 141, 305–314.

Veale, D. (2004). Body dysmorphic disorder. Postgraduate Medical Journal, 80, 67-71.

Veale. D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1, 113-125.

The American psychologist Marvin Zuckerman defined sensation-seeking as the “need for varied, novel and complex sensations and experiences, and the willingness to take physical and social risks for the sake of such experience.” This should mean that gamblers are higher than non-gamblers on sensation-seeking measures. However, studies in this area have provided contrasting results with some studies supporting the theory, some studies showing no difference between gamblers and non-gamblers, and others showing gamblers to be lower on sensation-seeking than non-gamblers!

In studies on extraversion, the findings have again proved contradictory. Since extraverts are highly sociable, crave excitement, and enjoy noisy and active environments the theory is that gamblers are more likely to be extraverted. Although some studies have indeed found gamblers to be more extraverted than control groups, other studies have found gamblers to have lower extraversion scores or have found no difference.

One personality trait that has received more consistent findings is that of locus of control. This personality trait refers to a person’s perception of how their own efforts effect events. For instance, ‘internal’ individuals attribute their experiences to their own actions whereas ‘external’ individuals attribute their experiences to chance. Research has shown that ‘internal’ individuals gamble more persistently when chasing losses because they believe all that is required is an increase in concentration and an overall improved effort in order to win. However, one of the problems with research into locus of control is that we do not know the direction of causality, that is, whether their particular locus of control preceded the gambling, or whether the gambling preceded their locus of control.

So why are there so few consistent results surrounding personality and gambling? One of the most obvious answers is that gambling is multi-faceted and not a unitary phenomenon. Treating all forms of gambling as equivalent in terms of underlying psychology, personality or motivation may cloud the issue rather than clarify it. For instance, can we really say that a regular lottery player has similar underlying psychology to a regular slot machine player? Is an online poker player similar to a roulette gambler? Of course not – and that is one of the reasons for inconsistent findings. Psychologists have tended to clump gamblers together as if they were a unified and homogenous group of people.

In addition, demographic differences – such as age, gender, and culture – may produce very different findings in motivation to gamble. For instance, an adult horserace gambler cannot be easily compared to an adolescent slot machine player; a male sports gambler cannot be easily compared to a female bingo player; and slot machine players in the UK cannot necessarily be compared to slot machine players in the US. What’s more, each individual gambling activity has its own unique structural differences. For instance, gambling can be differentiated in terms of stake size, time gap between each gamble, skill level, prize structures, size of jackpot etc. Each of these differences may have implications for the gambler’s motivations and the interplay between personality and the individual gambling activity.

It would appear from this brief overview that the usefulness and the value of psychometric-based personality studies remain doubtful. The notion that gamblers possess a unique set of variables or traits is a naive over-simplification and appears to be a fruitless direction for research. Gambling is complex and multidimensional, and personality factors are too ‘global’ to serve as the single cause. Research into gambling is still at a relatively early stage, and it is clear that a person’s gambling behaviour results from an interaction between many different variables including environmental, social, psychological and biological.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Benson, L., Norman, C. & Griffiths, M.D. (2012). The role of impulsivity, sensation seeking, coping, and year of study in student gambling: A pilot study. International Journal of Mental Health and Addiction, DOI 10.1007/s11469-011-9326-5.

McDaniel, S., & Zuckerman, M. (2003). The relationship of impulsive sensation seeking and gender to interest and participation in gambling activities. Personality and Individual Differences, 35, 1385-1400.

Myrseth, H., Pallesen, S., Molde, H., Johnsen, B. & Lorvik, I. (2009) Personality factors as predictors of pathological gambling. Personality and Individual Differences, 47, 933-937.

Parke, A., Griffiths, M.D. & Irwing, P. (2004). Personality traits in pathological gambling: Sensation seeking, deferment of gratification and competitiveness as risk factors, Addiction Research and Theory, 12, 201-212.

Wagenaar, W.A. (1988). Paradoxes of Gambling Behaviour. Erlbaum, London.

Zuckerman, M. (2005) Faites vos jeux anouveau: Still another look at sensation seeking and pathological gambling. Personality and Individual Differences, 39, 361-365.

The relationship between amputated limbs and sexual desire was little known about outside of particular academic circles, but was first brought to public attention in the letters pages of Penthouse in 1972 (see below). Although some thought these letters were a joke, it became clear that for a small minority of people, this was a rare but bona fide paraphilia.

Letter in Penthouse (May 1973): “I am 27, and have been an amputee since I lost my left leg at mid thigh when I was about eight. Probably because I have been an amputee for so long, I’ve never been shy about my lack of leg. For the last four years I have been married to a man who is fascinated by the stump of a female amputee. As a result I usually short skirts when I go out, allowing the end to show. When my husband is home, I wear short skirts so that my stump is fully exposed. I have never liked to use an artificial leg, and mostly I use a single crutch, and believe it ot not, a good ol’ peg leg…..probably many people think a peg leg is not very feminine, but it is practical for me. Sexually I feel I can compete with any two-legged girl. Because my husband is so turned on by the sight of my stump, I usually begin our lovemaking by undressing slowly at the foot of the bed. Once I have my clothes off, I lift my stump so that it points towards my husband and I begin to massage it. This excites my husband greatly, so he takes over and we go from there”

A more recent development in the world of amputee paraphilias has been the advent of the internet. This has brought global attention to people with disabilities and their admirers. Most of these sites are chat rooms and home pages for male devotees of female amputees. However, there are lots of other sites including female devotees of male amputees, particular sexual orientations (heterosexual, homosexual) and particular attractions (e.g. crutches, plaster casts, crutch, and neck braces). One specific bulletin board posting entitled “Bunion Love” requested “photos, videos, or correspondence of girls with deformed/crippled feet, or toe/toes amputated or who have severe bunions on their feet. The more severe, the better.”

Apotemnophilia: In 1977, the renowned US sexologist John Money of the John Hopkins University  coined the term “apotemnophilia” in the Journal of Sex Research. Apotemnophilia (Greek for “amputation love”) refers to being sexually excited by the fantasy or reality of being an amputee. This behaviour is often accompanied by obsessive scheming to convince a surgeon to perform a medically unnecessary amputation. This might seem to most people to be a type of masochism but reported case studies suggest that there is no erotization of pain itself – only of the healed amputated stump. To give you an inside look at the world of the apotomnophiliac, here are two real life case accounts from Professor Money’s files. Both involve people who had an erotic and obsessive desire to be an amputee.

Case Study 1: A man phoned up Professor Money’s sex research unit asking if he could have his leg amputated. He was told that this would not be possible but he continued to phone and write to the unit for the next four years. It was later discovered that he had made many attempts to self-inflict serious injury to his left leg. His obsession had been present since he was 13 years old in the form of self-amputee fantasies. On one notable occasion he hammered a stainless steel rod into his left leg and then tried to infect the open wound by smearing it on facial acne mixed with anal and nasal mucous. When his leg showed serious signs of infection he reported it to the hospital. Unfortunately his attempt failed as antibiotic treatment cleared the infection up. Looking into the childhood background, the most prominent early recollection was his left leg being severely burned by an overturned pot of boiling oatmeal at the age of two years old. This left him unable to walk for a year. However, there was little else in his family history to suggest the origins of such bizarre behaviour.

Case Study 2: A second man wrote to Professor Money for literature on the phenomenon of self-amputation. The patient reported that when he was engaged in homosexual or heterosexual intercourse he would fantasize about an amputee or being one himself. Pictures of both naked and dressed amputees were also used for masturbation purposes. Strangely, his fantasies were not always erotic and it was discovered that he could be aroused by visualizing an amputee engaging in an activity that required considerable effort on their part to overcome their physical handicap (e.g. an amputee water ski-ing). Although he considered many non-surgical ways to become an amputee, when it came down to it, he was too scared of inflicting pain to do it himself. Eventually he got a job working with handicapped people but was still attempting to find a surgeon who would amputate his leg. He continued to maintain that he would only be at peace with himself once he had been through the amputation. Looking into the patient’s background, it was discovered that he had been born with a clubbed right foot for which his father constantly criticized him. The condition was corrected during adolescence. His first amputation thoughts occurred at the age of eleven years old but these were not sexually explicit until the age of about fifteen when there was an amputee who worked with him. However, these childhood events are insufficient in explaining why it occurred.

Given the unconventional desires of the apotemnophiliac, it is perhaps unsurprising that self-mutilation occurs. To some extent, the condition resembles Munchausen’s Syndrome in that MS patients are obsessed with self-inducing symptoms repetitively for the sake of being a patient whereas the apotemnophiliac is obsessed with the symptom themselves for the sake of being an amputee.

Acrotomophilia: Acrotomophilia is a slightly different paraphilia to apotemnophilia and refers to being sexually aroused by a partner who is an amputee. They are excited by the stump or the stumps of the amputee partner and is dependent upon them for sexual arousal and attainment of orgasm. An example of this is given in the case study below (again from the files of Professor Money).

Case Study 3: This case involves a 47-year old man with an amputee fascination. His interest started at school when as an obese child he would try to do anything to avoid PE classes. It was at this stage he first started thinking that if he was an amputee he wouldn’t have to take part in these sessions. As he reached adolescence, he started to pretend to be an amputee by tying one of his legs up and making a peg to walk around on. It was during one of these “pretend” sessions that he experienced his first orgasm. As he reached late adolescence, he switched from fantasizing about being an amputee himself to wanting an amputee partner. He even made his own scrapbook turning Hollywood filmstars like Marilyn Monroe into amputees. He eventually got married and four years into his marriage he told his wife about his fantasies. She didn’t take the news well and it was never mentioned again for a further six years. However, later in the marriage, his wife would occasionally pretend to be an amputee while making love. Through an acquaintance, he developed friendships with a number of amputees and had sexual relationships with some of them. Interestingly, he claimed that his paraphilia was unlike other paraphilias because it was not always sexual and the fantasy was 24 hours a day. 

One of the interesting insights offered by the acrotomophiliac above was that he was part of an amputee network and was in regular correspondence with 55 other amputee devotees. Some of these were married to amputees while others had never even met one. Those who had ended up with amputee partners sometimes changed their focus and became “wannabe” amputees. With regards to the amputee fixation itself, around a quarter of the network were sharply focused on the stump itself and are very exact about what it should feel and look like (some being attracted to the scars – the more the better). Around a quarter of the network were really turned on by the asymmetry that amputation brings. For these people, bilateral amputees (for example, people with both legs amputated) were a turn-off.

In 1983, the first survey of male acrotomophiles was published in the journal Sexuality and Disability. The 195 acrotomophiles in the study were all customers of AMPIX (a company providing stories about and pictures of amputees) and were described as white, college educated, professional males. The results revealed that 75% had been aware of their interest in amputees by the age of fifteen. It was also reported that 55% of respondents had dated amputees, 40% had had sex with an amputee, and only 5% had married an amputee. 53% of the respondents had pretended to be an amputee (11% having done so publicly) and 71% had fantasized about being an amputee.

Another study completed in 1996 surveyed 50 acrotomophiles. The participants were again white college educated, professional males. Of these, 96% had been aware of their interest in amputees by their teens. In this sample, 41% had been married to or lived with an amputee, more than 43% had pretended to be amputees and 22% desired to become amputees. Using psychometric tests, the acrotomophiles were found on average to have high scores on self-esteem, but low scores on social interest, emotional stability and personal relations. Such tendencies have become a concern of people with disabilities since acrotomophiles demonstrate problematic behaviors. These include collecting names, addresses and phone numbers of disabled persons, obsessive and intrusive phone calls, letters and e-mail to persons with disabilities, attending and sometimes organizing disability-related events, lurking in public places to watch, take covert pictures of, talking to and touching disabled persons, and even engaging in predatory stalking.

Devotees, Pretenders and Wannabes: Dr. Robert Bruno, Director of the Post-Polio Institute (New Jersey) described two cases in an effort to understand the psychology of “devotees, pretenders and wannabes” (DPWs). So what exactly are DPWs? Put very simply:

• Devotees are non-disabled people who are sexually attracted to people with disabilities, typically those with mobility impairments and especially amputees.
• Pretenders are non-disabled people who act as if they have a disability by using assistive devices (for example braces, wheelchairs, and crutches). This may be done in private or in public so that they can ‘feel’ disabled or are perceived by others as having a disability.
• Wannabes actually want to become disabled, sometimes going to extraordinary lengths to have a limb amputated.

Dr. Bruno has also reported some of his case studies in the scientific literature:

Case Study 4: A 48-year old white female had been interested in men who had mobility impairments since she was a teenager. The first evidence of her interest was in high school when she dated a boy who had a severe limp. Although they kissed, she reports not being very sexually aroused by him and was interested, not in having intercourse, but in being with him and potentially seeing his affected leg. She then had a one-off date with an “obese and mildly retarded” wheelchair-bound man who she met through a personal ad. After their first passionate kiss she went to the bathroom and masturbated to orgasm by imagining herself having sex with the man. She did not want to have sex with him, as just the thought of him in his wheelchair was enough to give her an orgasm. She continued to search, obsessively at times, for disabled men. However, things changed when on a work trip she noticed a wheelchair behind the front desk of the hotel and first had the idea that she could pretend to be disabled. She started to do this regularly and after each trip out in a wheelchair she would return to her room and masturbate to orgasm while sitting in the wheelchair. The fantasies that aroused her were not even sexual. She would imagine her legs being paralyzed or picture herself being in a wheelchair. Alternatively she would imagine a paralyzed man walking on crutches, or his braces. This was enough to bring her to orgasm. Her ultimate fantasy was to meet a disabled man while she was pretending to be disabled and have sex. However, she denied strongly that she herself wanted to have a disability.

Looking into her childhood, she described herself as a lonely child whose parents ignored her. However, she recounted an incident when a local child, who had had polio and walked with crutches and leg braces, walked past their home on the way to school. Her parents appeared to show more concern for the boy than for her. She also remembered how her teacher would give more attention to the disabled children. After these experiences she would play in the family garage using croquet mallets as crutches and tieing sticks to her legs for braces. She also remembered finding her old baby carriage and pretending it was her wheelchair. Basically, she wanted to be a disabled child so she would be loved.

A variety of explanations have been offered for DPW’s attractions, desires and behaviours. The most appealing explanation involves the pairing in childhood of a disability-related stimulus with sexual arousal. For example, one plaster-cast devotee reported by Dr. Bruno had his first sexual experience with a girl who was wearing a leg cast. However, only 19% of respondents to the AMPIX survey related their interest in amputees to any kind of direct contact with a disabled person, and the overwhelming majority of devotees have reported their interest in disabled persons began long before puberty.

Attraction to disabled persons has also been related to homosexuality, sadism and bondage. However, recent surveys find no increased prevalence of homosexuality, sadism or interest in bondage among acrotomophiles. Several case studies have indicated that there may be a higher incidence of transvestites and transsexuals among DPW’s. However, the notion that an apotemnophile is a “disabled person trapped in a nondisabled body” is difficult to justify, as there is no ‘naturally-occurring’ state of disability that would correspond to the the two naturally-occurring genders. Others have suggested that DPW’s desires develop from a combination of a strict anti-sexual attitude in the child’s household, deprivation of maternal love and parental rejection in early childhood that creates a fear for survival and a self-generated fantasy for security.

Some case reports (like the one above) appear to suggest that deprivation of parental love, coupled with seeing parents’ positive emotional response to a disabled child, set the stage for attraction to the disabled. However, there may be other psychological factors at work as we shall see in the final case outlined below from the case notes of Dr. Bruno.

Case Study 5: A 45 year old white female with a history of childhood polio continually complained of arm and leg weakness, daily fatigue, disturbed sleep, imbalance and falling. Through her twenties and thirties she had many operations (on her hips and legs) and often became depressed. She had twice attempted suicide. In her early forties, she was given knee and ankle braces to treat her “instability.” Because of discomfort, she rarely wore these and began using crutches. The patient’s husband stated that she was again able to walk at home and in the hospital when she was in a psychotic state but not at any other time. He recalled that his wife had always wanted to have a “little disability” that would not limit her, like wearing braces on both legs, but only up to her calves. She thought that her mother and people in general would have treated her more kindly if she had been a disabled child. 

Her childhood desire to have a ‘little disability’ was something she thought would have allowed her to be “treated more kindly,” and her subsequent development of a Factitious Disorder, suggest that those with factitious physical disabilities can be combined with DPWs to create a diagnostic grouping that Dr. Bruno calls Factitious Disability Disorders. These are conditions in which disability – real or pretended – provide an opportunity to be loved and attended to where no such opportunity has otherwise existed. As noted earlier, Professor Money observed that apotemnophilia may share something in common with Munchausen’s Syndrome. However, Professor Money distinguishes between the Munchausen’s patient, who is obsessed with self-inducing symptoms repetitively for the sake of being a patient, and the apotemnophile who is supposedly satisfied with a single amputation.

The commonality between both conditions is they engage in the behaviour “for the sake of being a patient” (to receive the care and attention that would otherwise not be obtainable). Apotemnophiles need only one – albeit very extreme – medical intervention that leaves them with a lasting and obvious stigma of disability that they believe will permanently satisfy their need for love and attention. If the common psychological foundation of these conditions is that disability will satisfy unmet needs for love and attention, then there are only two factors that differentiate between DPWs and those with a factitious physical disability – the awareness of a desire to appear or actually become disabled and physically appearing to be disabled.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Berger, B.D., Lehrmann, J.A., Larson, G., Alverno, L. & Tsao, C.I. (2005). Nonpsychotic, nonparaphilic self-amputation and the internet. Comprehensive Psychiatry, 46, 380-383.

Brang, D., McGeoch, P. & Ramachandran V.S. (2008). Apotemnophilia: A neurological disorder. Cognitive Neuroscience and Neuropsychology 19, 1305-1306.

Bruno, R.L. (1997). Devotees, pretenders and wannabes: Two cases of factitious Disability Disorder. Journal of Sexuality and Disability, 15, 243-260.

First, M.B. (2005). Desire for amputation of a limb: Paraphilia, psychosis, or a new type of identity disorder. Psychological Medicine, 35, 919–928.

Dixon, D. (1983). An erotic attraction to amputees. Sexuality and Disability, 6, 3-19.

Everaerd, W.  (1983). A case of apotemnophilia: A handicap as sexual preference.  American Journal of Psychotherapy, 37, 285-293.

Griffiths, M.D. (2001). Stumped! Amputee fetishes. Bizarre, 44, 70-74.

Money, J. (1990). Paraphilia in females: Fixation on amputation and lameness. Journal of Psychological Human Sexuality, 3, 165-172.

Money, J., Jobaris, R. & Furth, G. (1977). Apotemnophilia: Two cases of self-demand amputation as a paraphilia.  Journal of Sex Research, 13, 115-125.

Money, J. & Simcoe, K.W. (1986). Acrotomophilia, sex and disability: New concepts and case report.  Sexuality and Disability, 7, 43-50.

Storrs, B. (1997). Devotees of disability, New Mobility, 6, 50-53.

Storrs, B. (1997). Amputees, Inc.: Amputees pitching products and themselves to devotees of disability. New Mobility, 7, 26-31.