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Give me strength: Muscle Dysmorphia as an addiction

Muscle Dysmorphia (MD) describes a condition characterised by a misconstrued body image in individuals interpret their body size as both small and weak even though they may look normal or even be highly muscular. Those experiencing the condition typically strive for maximum fat loss and maximum muscular build. MD can have potentially negative effects on thought processes including depressive states, suicidal thoughts, and in extreme cases, suicide attempts. These negative psychological states have also been linked with concurrent use of Appearance and Performance Enhancing Drugs (APED) including Anabolic Androgenic Steroids (AAS).

MD was originally categorised in 1993 by Dr. H.G. Pope and colleagues (in the journal Comprehensive Psychiatry) as Reverse Anorexia Nervosa, due to characteristic symptoms in relation to body size. It has been considered to be part of the spectrum of Body Dysmorphic Disorders (BDD) referring to a range of conditions that tap into issues surrounding body image and eating behaviours. Consequently, there is a lack of consensus amongst researchers whether MD is a form of BDD, Obsessive-Compulsive Disorder (OCD) or a type of eating disorder. Earlier this year, Andy Foster, Dr. Gillian Shorter and I published a paper in the Journal of Behavioral Addictions about the ‘Addiction to Body Image’ model, and arguing that MD could perhaps be conceptualized as an addiction.

Our ‘Addiction to Body Image’ (ABI) model attempts to provide an operational definition and to introduce a standard assessment across the research area. The ABI model uses my addiction components model (outlined is a previous blog) as the framework in which to define muscle dysmorphia as an addiction. For the purposes of our paper, body image was defined using Sarah Grogan’s definition (from her 2008 book Body image: Understanding body dissatisfaction in men, women, and children) who said it was a person’s “perceptions, thoughts and feelings about his or her body”. We argued that the addictive activity in MD is the maintaining of body image via a number of different activities such as bodybuilding, exercise, eating certain foods, taking specific drugs (e.g., anabolic steroids), shopping for certain foods, food supplements, and/or physical exercise accessories, etc.).

In the ABI model, the perception of the positive effects on the self-body image is accounted for as a critical aspect of the MD condition. The maintenance behaviours of those with ABI may include healthy changes to diet or increases in exercise. However, such behaviours can hide or mislead those with ABI away from the negative thought processes that are driving their addiction. It is in the cognitive dysfunction of MD where we believe there is a pathological issue, and why the field has encountered problems with the criteria for the condition. The attempt to explain MD in the same manner as other BDDs may not be adequate due to the cognitive dysfunction occurring in the context of the potentially positive physical effects via improvements in shape, tone, and/or health of the body.

We also argued that there is a difference in the cognitive dysfunction with a misconstrued self-body image compared to other BDDs. The cognitive dysfunction causes the individual with MD to have a misconstrued view of their own body image, and the person believes they are small and puny. This negative mindset has the potential to cause depression and other disorders, and may facilitate the addiction. Unlike other conceptualizations of MD in the BDD literature, we would argue that the agent of the addiction is the perceived body image that is maintained by engaging in secondary behaviours such as specific types of physical activity and food. The most important thing in the life of someone with MD is how their body looks (i.e., their body image). The behaviours that the person with MD engages in (such as excessive exercise or disordered eating) are merely the vehicles by which their addiction (i.e., their perceived body image) is maintained.

Based on empirical evidence to date, we proposed that Muscle Dysmorphia could be re-classed as an addiction due to the individual continuing to engage in maintenance behaviours that cause long-term psychological damage. More research is needed to explore the possibilities of MD as an addiction, and how this particular addiction is linked to substance use and/or other comorbid health conditions. Controversy about the conceptual measurement of the condition, has led to a number of different scales adapted from different criteria that may not fully measure the experience of MD.

However, a group of questions that might test the applicability of the ABI approach to measuring and conceptualising MD have not been asked. Questionnaires such as the Exercise Addiction Inventory and the Bergen Work Addiction Scale (two scales that I co-developed) could be adapted to fit MD characteristics. Adequate conceptualisation is key to explore the clinically relevant condition. This new ABI approach may also have implications for diagnostic systems around similar conditions such as other BDDs or eating disorders.

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

Additional input: Andy Foster and Dr. Gillian Shorter

Further reading

Andreassen, C.S., Griffiths, M. D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.

Foster, A.C., Shorter, G.W.& Griffiths, M.D. (2014). Muscle Dysmorphia: Could it be classified as an Addiction to Body Image? Journal of Behavioral Addictions, in press.

Griffiths, M.D. (1997). Exercise addiction: A case study. Addiction Research, 5, 161-168.

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

Griffiths, M. D., Szabo, A., & Terry, A. (2005). The Exercise Addiction Inventory: A quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39, 30-31.

Grogan, S. (2008). Body image: Understanding body dissatisfaction in men, women, and children. London: Routledge.

Mosley, P.E. (2009). Bigorexia: Bodybuilding and muscle dysmorphia. European Eating Disorders Review. 17, 191-198.

Murray, S. B., Rieger, E., Touyz, S. W., & De la Garza Garcia, Y. (2010). Muscle Dysmorphia and the DSM-V Conundrum: where does it belong? International Journal of Eating Disorders, 43, 483-491.

Nieuwoudt, J. E., Zhou, S., Coutts, R. A., & Booker, R. (2012). Muscle dysmorphia: Current research and potential classification as a disorder. Psychology of Sport and Exercise, 13, 569-577.

Olivardia, R. (2001). Mirror, mirror on the wall, who’s the largest of them all? The features and phenomenology of muscle dysmorphia. Harvard Review of Psychiatry, 9, 254–259.

Phillips, K. A. & Hollander, E. (1996). Body dysmorphic disorder.In T.A. Widige, A.J. Frances, H.A. Pincus, R. Ross, M.B. First, & W.W. Davis, Eds. DSM-IV Sourcebook, Volume 2. Washington DC: American Psychiatric Association.

Philips, K. A., Gunderson, C. G., Mallya, G., McElroy, S. L., & Carter, W. (1998). A comparison study of body dysmorphic disorder and obsessive-compulsive disorder. Journal of Clinical Psychiatry, 59, 568–575.

Pope, H. G., Jr., Gruber, A. J., Choi, P., Olivardia, R., & Phillips, K. A. (1997). Muscle dysmorphia. An underrecognised form of body dysmorphic disorder. Psychosomatics, 38, 548–557.

Pope, H. G., Jr., Katz, D. L., & Hudson, J. I. (1993). Anorexia nervosa and ‘‘reverse anorexia’’ among 108 male bodybuilders. Comprehensive Psychiatry, 34, 406–409.

Pope, C. G., Pope, H. G., Menard, W., Fay, C., Olivardia, R., & Phillips, K.A. (2005). Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body image, 2, 395-400.

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

The tooth, the whole tooth, and nothing but the tooth: A brief look at obsessive teeth whitening

Regular readers of my blog will know that I am always prepared to look at any claim of any behaviour being an addiction, compulsion or obsession irrespective of how trivial the behaviour might be perceived. One such behaviour is ‘teeth whitening’ which was included in a list of the ‘World’s Wackiest Addictions’ on the Oddee website. The short article claimed:

“Looks like some people can stop whitening their teeth, so much that it’s being considered a new addiction. Since bleaching is easy and effective, people can really get hooked. Two possible side effects of this addiction are tooth sensitivity and gum irritation. According to a report, in the US alone, people spent almost $1.4 billion on tooth whitening products and procedures in 2006”.

It will probably come as no surprise that there is no empirical research into teeth whitening as an addiction, compulsion or obsession (although there are some academic and clinical studies looking at other aspects of teeth whitening that I’ll return to at the end). However, I was surprised to find the Web MD website – a respected reference resource on all things health-wise – actually had an article on whether teeth whitening can become an addiction. The article noted that:

“Teeth whitening treatments are now the No. 1 requested cosmetic dental procedure, having increased more than 300% since 1996, according to the American Academy of Cosmetic Dentistry. At-home teeth whitening treatments have become increasingly popular as well. An array of over-the-counter tooth bleaching kits can be found in most any drugstore, discount store, or even grocery store. But there’s such a thing as too much of a good thing. While most would stop short of calling it an addiction, dentists say some people do overdo it in the quest for the perfect smile”.

The same article also quoted Dr. Marty Zase (President of the American Academy of Cosmetic Dentistry) who said: “Yes, there definitely is a tendency of people to overuse [teeth whitening products], although most people don’t”. A number of (populist and non-academic) articles that I read online about obsessive teeth whitening mentioned the behaviour in the context of ‘bleachorexia’ or ‘dentorexia’. (The online Urban Dictionary defined a ‘dentorexic’ as When someone has white teeth but they think that their teeth are yellow so they obsess over brushing their teeth/whitening them. Similar to anorexia but involving an obsession over teeth rather than weight”).

An article on the Farah Queen website examined ‘bleachorexia’ (‘Teeth whitening addiction unraveled’) and claimed that some individuals become obsessed with the process of teeth whitening…[the] repetitive desire to conduct teeth bleaching”. Typical behaviours of bleachorexics included constantly looking in mirrors at one’s own teeth (looking for signs of stains, spots, and discolouration) and a constant feeling of dissatisfaction with the colour of one’s teeth. The article claims that:

“[Bleachorexia is the term] referred to as the addiction with bleaching or teeth whitening to the extent that their oral dental health is already affected. People with bleachorexia don’t have to be admitted to a hospital to be cured, but it does pose multiple oral health risks in the process. The solution is just to accept that the teeth whitening products don’t really whiten the teeth but just remove the stains in their teeth. It is also recommended to avoid as much as possible the factors that causes stains and discoloration of teeth, such as coffee, red tea, soda, etc.”.

The article then goes on to list some of the “symptoms of bleaching addiction”. This includes hypersensitive teeth (due to tooth enamel erosion), oral irritation (affecting gums, palate, and throat), and dizziness (due to accidental swallowing bleaching solutions). This is because bleaching solutions excessively can cause damage to the enamel, or the outer coating of the teeth, which results to sensitivity of your teeth. This appears to be backed up by a US report on ABC News that claimed that when it came to teeth whitening some people simply do not know when to stop, and that excessive teeth whitener use can cause permanent damage to teeth and gums. A New York cosmetic dentist, Dr. Nancy Rosen, said:

“People just want that Hollywood white, bright smile, and they are becoming obsessed with it. When people abuse teeth whitening products, the results aren’t pretty. The edges of your teeth will become bluish-translucent in color, and that is irreversible. Your teeth can become very sensitive. You can harm the gum tissue and burn it away. They don’t see that their teeth are looking translucent,” Rosen said. “They don’t see they have a problem. But a dentist can tell. I think most systems are very safe and effective. If you’re not going to read the directions, any of these products can be dangerous. And there is no product that you can use, and use, and use that won’t harm your teeth. If you are going to bleach your teeth, drink staining liquid through a straw”.

An online article by Dr. Chris Iliades (‘Could you have bleachorexia?’) defined bleachorexia as “an addictive obsession with bleaching their teeth to the point that it’s affecting their dental heath”. However, it did then add that those suffering from it “probably don’t need a 12-step program – [but may] need to set more realistic expectations [about] teeth-whitening products”. Addictive terminology appears in almost every article that I have read on teeth whitening. For instance, an article by Sarah Bernard in the New York Magazine began her article with the following:

Dr. Jennifer Jablow calls them ‘bleaching anorexics’. Dr. Larry Rosenthal prefers ‘bleaching junkies’. Peering into a patient’s mouth, Dr. Jonathan Levine can spot one in eight seconds. Dentists in the city are seeing more and more DIY tooth-whitening addicts who are abusing over-the-counter products…often to the point of pain and permanent damage. Michele Hallivis, 28, a biotech sales executive, began with ordinary whitening toothpaste, then upgraded to strips, paint-on whiteners, and finally a tray-and-gel product (where the solution is squeezed into a retainer like tray and worn for about an hour). She’d marinate her teeth – and inadvertently her gums – in a 6% peroxide solution. And because she kept the solution in too long, her gums became so sensitive”.

Here, the use of the word ‘junkies’ and a case study showing what appears to be tolerance (i.e., the needing of more and more, and stronger and stronger teeth whitening products to get her ‘fix’) implies some kind of addiction. However, I have yet to read any case study (even anecdotally) that fulfils my six criteria for addiction. However, the psychology of some aspects of teeth whitening have been investigated.

A recent 2013 paper in the Journal of Korean Society of Dental Hygiene by Dr. Kyeong-Hee Lee and colleagues examined awareness towards tooth whitening among 395 Koreans. They found that the majority of the participants wanted to whiten their teeth and most (65%) had whitened their teeth because it was easy to do (with 50% having done it themselves). They also reported that smoking and drinking coffee had no significant influence on the intention to whiten teeth either by gender, age, and marital status.

However, having white teeth doesn’t appear to influence attractiveness. A study published in a 2003 issue of the psychology journal Perceptual and Motor Skills by Dr. Alexis Grofosky examined whether having whiter teeth affected people’s perception of attractiveness. In their experiment they manipulated the colour of male and female teeth in photographs. They found that participants in their study found no difference in attractiveness between those with brilliantly white teeth and those that were not brilliantly white. However, they did note that having really white teeth might increase the self-esteem and confidence of those with such teeth (but this was not a variable examined in their study).

This does appear to be the case as a 2013 study by Dr. Corina Cristescu and colleagues in the Journal of Romanian Medical Dentistry assessed dental patients’ attitudes towards dental somatoform disorders damaging facial aesthetics, and how they felt after dental treatment. They surveyed 230 patients (92 females and 138 males; aged 20-63 years). They found that those with a poorer educational background were less preoccupied with their physical and anatomic appearance, and that people felt better about themselves after aesthetic dental treatment (including teeth whitening).

Another area where teeth whitening has been examined from a psychological perspective has been in the area of body dysmorphic disorder (a condtion that I examined in a previous blog). Body dysmorphic disorder is a psychiatric condition that affects about 1-2% of Western populations and in the American Journal of Orthodontics and Dentofacial Orthopedics, Dr. M. Pole wrote an awareness-raising paper for orthodontists about the disorder, as it is believed that BDD concerning perceived dental imperfections is on the increase. A recent paper in the journal Behavioral Dentistry by Dr. A De Jongh also made the same point that one of the many types of BDD include those people who feel that their teeth are not white enough and need cosmetic surgery to improve their psychological condition.

A short 2010 article by Dr. M. Ali and colleagues in the British Dental Journal reported that they encounter patients with many psychiatric conditions including dental anxiety and phobia, obsessive compulsive disorder, hypochondriasis, psychogenic facial pain, eating disorders, drug and alcohol misuse, depression, schizophrenia and bipolar disorder. However, they singled out BDD as an important disorder that dentists should be aware of. They noted:

“From a dental point of view, patients present with disproportionate concerns about relatively minor cosmetic or aesthetic lesions, or the delusion that a normal part of their body is abnormal. A delusion is a fixed, false belief out of keeping with normal cultural and educational values…Such patients are more common than perhaps realised, and are very difficult to treat successfully as their visions of the anticipated results are not always realistic. They often display narcissistic personality traits, and there is a link with depression and anxiety. Often they have had multiple interventions…Patients with BDD may seek conventional dental treatment, for example cosmetic dentistry, implant surgery, [and] tooth whitening”.

However, Dr. A. De Jongh and colleagues published a 2008 study in the British Dental Journal and claimed there ws no reason to assume that BDD plays a significant role in the majority of people who seek cosmetic dental care. They surveyed 879 Dutch citizens for characteristics of BDD. Only one BDD feature (i.e., a preoccupation with a defect of appearance) was reported as a significant predictor of undergoing cosmetic dental treatments. Patients with such preoccupation were nine times more likely to consider tooth whitening, and six times more likely to consider orthodontic treatment. They were also five times more likely to be dissatisfied about their most recent treatment.The authors concluded that a preoccupation with physical appearance was a motivating factor for undergoing certain types of cosmetic dental procedures (including teeth whitening).

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

Further reading

Ali, M., Elrasheed, A., & Cousin, G. C. S. (2010). Dysmorphic disorder. British Dental Journal, 209(5), 198-198.

Cristescu, C., Apostu, A., Virvescu, D., Apintilesei, A., & Burlui, V. Study on the psychological impact of dental somatoform disorders. Journal of Romanian Medical Dentistry, 13, 54-59.

De Jongh, A. (2013). Cosmetic Dentistry: Concerns with Facial Appearance and Body Dysmorphic Disorder. Behavioral Dentistry, 109.

De Jongh, A., Oosterink, F.M.D., Van Rood, Y. R., & Aartman, I.H.A. (2008). Preoccupation with one’s appearance: a motivating factor for cosmetic dental treatment? British Dental Journal, 204, 691-695

Grosofsky, A., Adkins, S., Bastholm, R., Meyer, l., Krueger, l., Meyer, J., & Torma, P. (2003). Tooth color: effects on judgments of attractiveness and age. Perceptual and Motor Skills, 96(1), 43-48.

Lee, K-H., Park, C-H., & Kim, S-K. (2013). Awareness and satisfaction on tooth whitening. Journal of Korean society of Dental Hygiene, 13, 605-613

Oddee (2008). World’s Wackiest Addictions. November 5. Located at: http://www.oddee.com/item_96496.aspx

Polo, M. (2011). Body dysmorphic disorder: A screening guide for orthodontists. American Journal of Orthodontics and Dentofacial Orthopedics, 139, 170-173.

Cock tales: A brief look at Penile Dysmorphic Disorder

In a previous blog, I examined Body Dysmorphic Disorder (BDD). At its simplest level, BDD is a distressing, handicapping, and/or impairing preoccupation with an imagined or slight defect in body appearance that the sufferer perceives to be ugly, unattractive, and/or deformed. BDD sufferers can think about their perceived defect for hours and hours every day. The International Classification of Diseases (ICD-10) criteria for BDD is:

  • Persistent belief in the presence of at least one serious physical illness underlying the presenting symptom(s), even though repeated investigations and examinations have identified no adequate physical explanation, or a persistent preoccupation with a presumed deformity or disfigurement.
  • Persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or abnormality underlying the symptoms.

One particular body part that has been the focus of some research in the BDD field is that of genitalia. Many men worry about the size of their penis and think it is too small. This is perfectly normal and the worry or concern is highly unlikely to be a symptom of BDD. In a 2004 issue of the Postgraduate Medical Journal, British psychiatrist Dr David Veale reported that although there are broad similarities between the genders in BDD, there are some differences. For instance, men with BDD show a greater preoccupation with their genitals, and women with BDD are more likely to have a co-morbid eating disorder. Dr. David Sarwer (writing in a 2006 issue of Plastic and Reconstructive Surgery) asserted that the rate of body dysmorphic disorder should be examined among patients re-questing atypical procedures and cites the example of those individuals requesting genital surgery.

Back in 2008, Channel 4 in the UK had a television series called Penis Envy. The first episode (The Perfect Penis) featured a US psychology student who paid $4000 to have his penis lengthened by cutting the ligament in his pubis. Such actions might be indicative of BDD but the programme didn’t explore this facet. Following such operations, men then have to spend the following weeks suspending a weight from their penis for at least eight hours a day. For all the financial and physical burdens faced, the average increase in length is only 0.5-3cm (with official statistics being closer to 0.5cm than 3cm). Other methods of increasing genital size include the injection of silicon into the penis (although this is dangerous and can result in a silicon embolism).

Dr. Stephen Snyder (Associate Clinical Professor of Psychiatry, Mount Sinai School of Medicine, New York, US) was interviewed about (so-called) ‘Penile Dysmorphic Disorder’ (PDD) in an online Psychology Today article. He was quoted as saying:

I don’t know of any statistics on [PDD]. Anxiety or insecurity about penis size is extremely common in men. It would be difficult to determine how frequently the more serious condition of penis-focused BDD occurs. People with BDD tend to avoid mental health specialists…It’s much more likely I think that a man with penile BDD will purchase penis enlargement equipment or consult a surgeon than consult someone like me…Some people seem to have an innate tendency for obsessive thinking. Why some of these people develop BDD, and others OCD or Anorexia Nervosa is unknown…A man who begins to obsess about the size of his penis may begin to compulsively and repeatedly measure his erections, and to avoid dating because he’s convinced he’ll be humiliated. Then the whole thing can spiral out of control, until ultimately he’s online studying penis enlargement techniques”.

A 2006 study led by Dr. J. Lever and published by Psychology of Men and Masculinity reported that in an online survey of over 52,000 participants, most male participants rated their penis as average (66%) and only 22% as large and 12% as small. Among the female participants, around 85% of women were satisfied with their partners’ penile size, while only 55% of men were satisfied, with 45% wanting to be larger (and 0.2% to be smaller).

Just recently, Dr. Warren Holman highlighted the case of ‘Sam’, a 17-year-old white male from a middle-class Jewish family living in Midwest USA with penile dysmorphic disorder (in a 2012 issue of Social Work in Mental Health). As Dr. Holman reported:

“Sam had stopped attending school several weeks earlier, and on many days would not even leave his home. He said he wanted to remain at home and away from school because, ‘My penis is shrinking and people can tell.’ Sam reported he had had his anxiety about his penis for about a year, but until recently had been able to reason himself out of it…Sam was well related, and his mental status was unremarkable except for his belief about his penis”.

Dr. Holman believed that Sam’s conviction that his penis was shrinking (and people could tell) suggested three possible diagnoses (i.e., social phobia; BDD and/or delusional disorder of the somatic type; or schizophrenia). Holman eventually reached the conclusion that Sam’s beliefs were due to BDD although did say that it “may be in a prodromal phase of schizophrenia”. Sam was treated via a form of psychodynamic counselling (which much to the disappointment of Holman ultimately failed perhaps because of initial misdiagnosis).

In 2007, British urologists Dr. Kevan Wylie and Dr. Ian Eardley published a review on penile size in BJU International. They summarized all of the studies on penile size that have examined flaccid penis length, stretched penis length, erect penis length, flaccid penis girth and erect penis girth. They reported that:

“Stretched penile length in these studies was typically 12–13 cm, with an erect length of 14–16 cm. For girth, there was again remarkable consistency of results, with a mean girth of 9–10 cm for the flaccid penis and 12–13 cm for the erect penis…Concern over the size of the penis, when such concern becomes excessive, might present as the ‘small penis syndrome’ [SPS], an obsessive rumination with compulsive checking rituals, body dysmorphic disorder, or as part of a psychosis”.

However, they did also assert that more research was required on the effects of race and age on penile length. Wylie and Eardley speculate that SPS (or ‘locker room syndrome’ as they also call it) originates in childhood following the sight of their father’s, elder sibling’s and/or older friend’s penis. This appears to have support from a 2005 study (also published in BJU International). Dr. N. Mondaini and Dr. P. Gontero surveyed men who thought they had a small penis at an andrology clinic and reported that nearly two-thirds said their SPS had begun in childhood (63%) with the rest saying it began in adolescence (37%).

Wylie and Eardley also examined the treatment options of men with SPS and also examined the evidence of commercial penis extending techniques. They concluded that:

“It is recommended that the initial approach to a man who has SPS is a thorough urological, psychosexual, psychological and psychiatric assessment that might involve more than one clinician…Conservative approaches to therapy, based on education and self-awareness, as well as short-term structured psychotherapy [cognitive-behavioural therapy] are often successful, and should be the initial interventions in all men. Of the physical treatments available, there is poorly documented evidence to support the use of penile extenders. More information is need on the outcomes with these devices. Similarly, there is emerging evidence about the place of surgery and there are now several reports suggesting that dividing the suspensory ligament can increase flaccid penile length”.

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

Further reading

Goodman, M.P. (2009). Female Cosmetic Genital Surgery. Obstetrics and Gynecology, 113, 154-159.

Holman, W.D. (2012). “My Penis Is Shrinking and People Can Tell”: A Confusing Case of Apparent Body Dysmorphic Disorder. Social Work in Mental Health, 9, 319-335.

Morrison, T.G., Bearden, A., Ellis, S.R. & Harriman, R. (2005). Correlates of genital perceptions among Canadian post- secondary students. Electronic Journal of Human Sexuality, 8. Located at: http://www.ejhs.org/volume8/GenitalPerceptions.htm

Lever, J., Fredereicjk, D.A. & Peplau, L.A. (2006). Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men and Masculinity, 3,129-143.

Mondaini, N. & Gontero, P. (2005). Idiopathic short penis: myth or reality? BJU International, 95, 8–9.

Sarwer, D.B. (2006). Body Dysmorphic Disorder and cosmetic surgery. Plastic and Reconstructive Surgery, December, 168e-180e.

Snyder, S. (2011). When size obsession gets out of hand. Psychology Today, June 11. Located at: http://www.psychologytoday.com/blog/sexualitytoday/201106/when-size-obsession-gets-out-hand

Sondheimer, A. (1988). Clomipramine treatment of delusional disorder-somatic type. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 188-192.

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

Wylie, K.R. & Eardley, I. (2007). Penile size and the ‘small penis syndrome’. BJU International, 99, 1449–1455.

Cutting womb flaw: A brief overview of female genital self-mutilation

In a previous blog I examined the rare act of genital self-mutilation (GSM) in males. More rare are cases of female genital self-mutilation. Back in 1970, Goldfield and Glick first described a syndrome of dysorexia (i.e.. disordered and/or unnatural appetite) and GSM in the Journal of Nervous Diseases. Of the cases reported since 1970, the majority of cases reported have had personality disorders (typically borderline personality disorder) and a history of childhood sexual abuse. In the Journal of Sex and Marital Therapy, Wise and colleagues categorized female GSM into three groups: (i) patients with personality disorders, (ii) self-induced aborters and (iii) psychotic patients. This slightly differs from male GSM where the cases have been categorized into: schizophrenics, transsexuals (i.e., those with a gender identity crisis), those with complex cultural and religious beliefs, and a small number of severely depressed people who engage in GSM as part of a suicide attempt.

Excluding injuries secondary to self-induced abortion or the insertions of foreign bodies in children, to date, only a handful of female genital self-mutilation have been reported in the literature. Some papers have discussed the differences between self-induced abortion and GSM. However, the differential diagnosis has become increasingly rare because abortion laws have become liberal in many countries.

An early 1957 case in the Journal of Mount Sinai Hospital described a patient who mutilated her vagina on four occasions with a hatpin and knitting needle in late pregnancy that eventually led to a Caesarean section. The 1970 case in the Journal of Nervous Diseases (above) involved a 19-year old female who scratched and gorged her internal genitalia with her fingernails and led to a lot of vaginal bleeding that needed medical attention. A 1972 case in the Archives of General Psychiatry reported the case of a woman who lacerated her vulva with a razor blade.

Following one instance of sexual intercourse with her boyfriend, she feared pregnancy and subsequently penetrated her vagina with a knitting needle. This particular act was not her first episode of self-mutilation. For instance, she had previously swallowed dangerous metal objects, cut her wrists, and had inflicted a deep laceration on her left breast. She also began inserting objects into her vagina including (on one occasion) a twig that had to be medically removed. She later lacerated her vulva and vagina with a knitting needle and a kitchen knife. While in hospital she smashed a window on the gynaecology ward and slashed her arm. Several months later, she again ended up in casualty having cut her vagina with scissors on the previous day, sustaining multiple superficial lacerations of the vagina and cervix.

A detailed case study was reported in 1974 by Simpson and Anstee in the Postgraduate Medical Journal. The authors reported that her self-mutilating behaviour shared several features with the typical wrist cutters (e.g., planning the incident carefully, enjoying the anticipation of the event). She felt no pain when cutting and felt relief and fascination when watching blood flow from her vagina.

There have been a few reports of female GSM associated with psychosis and one 1989 report in the Journal of Sex and Marital Therapy reported an association between, an isolated delusional system, and body dysmorphic disorder. In fact, the feelings of a distorted body image have been noted in a couple of cases where the women view their genitals as abnormal, and as a consequence tried to remove them.

In a 2005 issue of the German Journal of Psychiatry, Dr. Silke Marckmann and colleagues reported the case of a female with paranoid psychosis who had injured her external genitals in an attempt to stop coenaesthetic dysaesthesias (i.e., feelings of abnormal sensations which in this case was described as “feeling like an electric current” running through her genitals). They also noted that in this particular case, secondary erotomania was a feature associated with female GSM. (Erotomania is a type of delusion where the affected person believes that another person is in love with them). The authors also reported that:

“In the last months before hospital admission she felt that the dysaesthesias did not allow her to concentrate on anything else which included eating. She lost 10 kg weight in the 2 months before she agreed to hospital admission. She then reported, that she had been hitting herself repeatedly in the genital area in the attempt to stop the dysaesthesias”

However, the condition is complex and as Dr Nagaraja Rao and colleagues highlighted in the Indian Journal of Psychiatry, thatgenital self mutilation like any other serious self injury is not a single clinical entity and it occurs in any psychiatric condition with corresponding psychopathology”.

Marckmann and colleagues believe that compared to male GSM, female GSM might be underreported. This is because they speculate there may be a bias towards those individuals with GSM needing acute medical attention (e.g., men cutting of their penis and/or testicles). Female self-mutilators may find it easier to hide their chronic self-inflicted genital injuries and not seek immediate medical help. Such GSM injuries may be more likely to be spotted by gynaecologists (and as Marckmann and colleagues note, there have been increased reporting of female GSM case studies in gynaecological journals such as the Journal of Obstetrics and Gynaecology and European Journal of Obstetric, Gynecological and Reproductive Biology).

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

Further reading

Ajibona, O.O. & Hartwell, R. (2002). Feigned miscarriage by genital self-mutilation in a hysterectomised patient. Journal of Obstetrics and Gynaecology, 22, 451.

Alao, A.O., Yolles, J.C & Huslander, W. (1999). Female genital self- mutilation. Psychiatric Services, 50, 971.

French, A.P.& Nelson, H.L. (1972). Genital self-mutilation in women. Archives of General Psychiatry, 27, 618.

Gersble, M.L., Guttmacher, A.F. & Brown, F. (1957). A case of recurrent malingered placenta praevia. Journal of Mount Sinai Hospital, 24, 641.

Goldfield, M.D. & Glick, I.R. (1970). Self-mutilation of the female genitalia: a case report. Diseases of the Nervous System, 31, 843.

Habek, D., Barbir, A., Galovic, J., Habek, J.C. et al. (2002). Autosection of the prolapsed uterus and vagina. European Journal of Obstetric, Gynecological and Reproductive Biology, 103, 99-100.

Krasucki, C, Kemp, R., & David A. (1995). A case study of female genital self-mutilation in schizophrenia. British Journal of Medical Psychology, 68, 179-186

Marckmann, S., Garlipp, P., Krampfl, K., & Haltenhof. H. (2005). Genital self-mutilation and erotomania. German Journal of Psychiatry. Located at: http://www.gjpsy.uni-goettingen.de

Simpson, M.A. & Anstee, B.H. (1974). Female genital self-mutilation as a cause of vaginal bleeding. Postgraduate Medical Journal, 50, 308-309.

Standage, K.F., Moore, J.A,. & Cole, M.G. (1974). Self-mutilation of the genitalia by a female schizophrenic. Canadian Psychiatric Association Journal, 19, 17-20.

Wise, T.N., Dietrich, A.M. & Segall, E. (1989). Female genital self- mutilation: Case reports and literature review. Journal of Sex and Marital Therapy, 15, 269-274

Aural wrecks: A brief look at self-mutilation of the ear

If I was playing a word association game and said the words ‘self-inflicted ear mutilation’, I would hazard an educated guess that the first thing that popped into most people’s minds would be the Dutch artist Vincent Van Gogh. On the evening of December 23, 1888, in Aries (France) Van Gogh (in a state of deep depression) cut off the lower part his own right ear with a razor (and later immortalized in his famous painting Self Portrait With Bandaged Ear). Earlier in the day he had threatened his long-time friend and artist Paul Gaugin with a razor and was not in a good state of mind (both that day and in life more generally). Van Gogh had become a heavy smoker and heavy drinker and had taken a liking to the alcoholic drink absinthe. After cutting off his ear, he took it over to a local brothel and gave it to a prostitute called Rachel (telling her to take good care of it). He would have died of blood loss but the local police took him to the hospital.

This incident has given rise to what has been called the Van Gogh Syndrome which has now become a catch-all term for self-mutilation, particularly in relation to amputation of a bodily extremity (such as the cutting off of one’s own penis, or the removal of one’s own eye). Such actions may be due to a wide range of conditions including psychoses, mood disorders (e.g., clinical depression), body dysmorphic disorder, or as a component of Lesch-Nyhan syndrome (a genetic disorder that affects how the human body builds and breaks down purines).

Van Gogh would have been classed as a ‘psychotic self-mutilator’ in psychiatrist Karl Menninger’s self-mutilation typology developed in the 1930s. He proposed that self-mutilators fall into one of six categories:

  • Neurotic self-mutilators: These individuals comprise nail biters and pickers, extreme hair removal and those seeking unnecessary cosmetic surgery.
  • Religious self-mutilators: These individuals comprise self-flagellators and/or genital self-mutilators.
  • Puberty rite self-mutilators: These individuals comprise those who engage in hymen removal, circumcision or clitoral alteration.
  • Psychotic self-mutilators: These individuals engage in eye or ear removal, genital self-mutilation and extreme amputation.
  • Organic disease self-mutilators: These individuals comprise those who engage in repetitive head banging or hand biting, intentionally fracturing fingers and eye removal, due to diseases such as encephalitis or disorders such as severe mental retardation.
  • Conventional self-mutilators: These individuals comprise normal people that engage in customary or conventional forms of self-mutilation (that most would argue is not self-mutilation at all, e.g., nail clipping, hair trimming, and beard shaving).

More recent typologies tend to talk about self-harm rather than self-mutilation and class such behaviour into one of three types (i.e., psychotic, organic or typical). Again, Van Gogh would be classed as a psychotic self-harmer:

  • Psychotic self-harmers: These individuals comprise those who remove or amputate body parts (e.g., eyes, limbs, ears, genitals, digits). In these cases, body part removal is carried out in response to hallucinations bought on by psychosis. Unsurprisingly, this is the most severe type of self-harming.
  • Organic self-harmers: These individuals comprise those who self-harm in the form of behaviours such as head-banging and lip-biting because of conditions such as Autistic Spectrum Disorders, developmental disabilities, and other similar disorders. Here the self-harm is a consequence of physical or chemical issues in the body.
  • Typical self-harmers: These individuals comprise those who self-harm in the form of self-cutting, burning, hair-pulling (trichotillomania), skin-picking (dermotillomania), biting, hitting, interference with wound healing, scratching or bone-breaking. Here, the self-harm is initiated by emotional or psychological trauma that is unrelated to psychotic or organic conditions. This is the most common type of self-harming.

In a 2006 issue of the Journal of Deaf Studies and Deaf Education, Dr. David Veale reported that major self-injurious behaviours tend to “be very isolated events and consists of severe or life-threatening tissue damage, such as self-castration, eye nucleation, or less commonly self-amputation of a limb or ear. They mainly occur in young psychotic men or older males with psychotic depression usually in the context of command auditory hallucinations or delusions of guilt”.

Despite the fact that self-inflicted ear mutilation is well documented, there are surprisingly few published case studies. In 1989, Dr. J. Silver and colleagues published a case study of self-inflicted ear mutilation (as part of wider self-mutilation) in the journal Psychosomatics. Their case was a 35-year old male paranoid schizophrenic who presented for treatment following dermatological self-mutilation following severe lacerations (including the ear, arms, and face). They concluded that the self-mutilation behaviour appeared to be associated with his psychotic symptoms, and that the self-mutilation was exacerbated by failure to take his neuroleptic medication.

Dr. Christopher Alroe and Dr. Venkat Gunda reported some cases of self-inflicted ear mutilations in a 1995 issue of the Australian and New Zealand Journal of Psychiatry. They presented three cases of self-amputation of the ear by three white right-handed men. All three men had psychiatric problems (one having schizophrenia and two having personality disorders. They compared their cases with that of van Gogh. The authors also surveyed all Australian and New Zealand prisons to determine the frequency of self-mutilation of the ears within the last five years. They found only one other case. Based on the cases, they argued that connections exist between the self-amputees and supports the notion that self-mutilation is “contagious”.

It is also worth noting that there are cases of people who have cut off their ears but would not be classed as psychotic because they have done it for a very specific reason. The most recent case was that of British prisoner Michael O’Donnell who (on May 2, 2010) cut off his ear so that he could escape from an ambulance while he was being transported to hospital for treatment. In the end, it was all in vain as he was caught and re-arrested three weeks later.

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

Further reading

Alroe, C.J., & Gunda, V. (1995). Self-Amputation of the Ear: Three Men Amputate Four Ears within Five Months. Australian and New Zealand Journal of Psychiatry, 29, 508-512.

Edwards, G. (1998). A brief history of ear mutilation. Deluxe. Located at: http://rulefortytwo.com/articles-essays/gallimaufry/ear-mutilation/

Menninger, K. (1935). A psychoanalytic study of the significance of self-mutilation. Psychoanalytic Quarterly, 4, 408-466.

Menninger, K. (1938). Man Against Himself. New York: Jovanovich.

Silva, J.A., Leong, G.B. & Weinstock, R. (1989). A case of skin and ear self-mutilation. Psychosomatics, 30, 228-230.

Press Association (2010). Prisoner who cut off ear to escape is recaptured. The Guardian, May 28. Located at: http://www.guardian.co.uk/uk/2010/may/28/prisoner-cut-off-ear-recaptured

Veale, D. (2006). A compelling desire for deafness. Journal of Deaf Studies and Deaf Education, 11, 369-372.

Shrink rap: A beginner’s guide to Koro in females

In a previous blog, I examined Koro (the so-called genital retraction syndrome). This is a culture-bound syndromes found primarily in Asian regions (e.g., China, Singapore, Thailand, India). Koro refers to a kind of “genital hysteria” with “terror stricken” individuals (typically male) believing that that their genitals are shriveling, shrinking up, retracting into the abdomen and/or disappearing, and that this ultimately leads to death. Writing in a 1997 issue of the Journal of Psychology and Human Sexuality, Dr. J.T. Cheng noted of Koro that it:

“Is best perceived as a social malady supported by cultural myths which tend to affect young people who are deprived of proper sex information to explain their physical development”.

Koro is rarely described in women but published case studies in the academic literature do exist. All of these female cases report that the affected women reported the shrinking of the vulval labia, nipples, and/or the breasts. The interesting thing about Koro is that all the body parts affected (penis in males; breasts, nipples and labia in women) are those that naturally swell and shrink in response not only in relation to sexual arousal but also in response to temperature and climate changes, depression, anxiety, stress, fear, illness, and/or psychoactive drug ingestion.

Most Koro epidemics while primarily comprising males always appear to involve a small minority of females. For instance, Dr. Robert Bartholomew’s book Exotic Deviance reports the Koro epidemic that occurred in northeast Thailand at the end of 1976 that affected approximately 2,000 people (primarily rural Thai residents in the border provinces of Maha Sarakham, Nakhon Phanom, Nong Khai and Udon Thani). As with most Koro epidemics, the symptoms included the perception of genital shrinkage and impotence among males, whereas females typically reported sexual frigidity, with breast and vulva shrinkage. The origins of the epidemics can vary and include the supernatural. For instance, in a 1986 issue of the journal Curare, Dr. W.G. Jilek described an atmosphere of collective fear of ghosts during a Koro epidemic in Zhanjiang town (Guangdong in China). Those affected believed that ghosts would make the genitals of men and breast of women shrink and disappear into the abdomen and chest. To end the Koro epidemic, the villagers’ drove the ghosts out of their village used drum-beating, bell ringing and bursting of firecrackers.

In 2005, Vivian Dzokoto and Glenn Adams published a paper in Culture, Medicine and Psychiatry examining genital shrinking epidemics in West Africa. More specifically, they examined all media reports of genital shrinking in six West African nations between January 1997 and October 2003 (comprising a total of 56 media reports). Most of the reports were of males but Dzokoto and Adams noted that three Ghanaian news reports included females. All three women reported experiencing shrinking breasts and/or changes to their genitalia. They also noted that:

“One report described a woman whose ‘private parts sealed.’ Another report described a woman who reported that her genital organ (unspecified) was vanishing. Again, it is unclear whether references to sealing and vanishing of female genitalia represent different ways of describing the same experience or represent qualitatively distinct forms of subjective experience.In all reported cases, experience of symptoms tended to be brief and acute. There were no reported cases of recurrence”.

The earliest report of Koro in a female was arguably be in a 1936 book chapter entitled ‘Psychiatry and Neurology in the Tropics’ by Wulfften Palthe. Since then there have been sporadic reports of female Koro in the literature. One of the more notable cases reported was by Kovács and Osváth in a 1998 issue of the journal Psychpathology. This case was unusual because it was a case of genital retraction syndrome in Hungary (although the woman reported was a Korean woman by background).

In a 1982 issue of the Indian Journal of Psychiatry, Dr. D. Dutta and colleagues reported on the (then) recent epidemic of Koro that occurred in four districts of Assam (June 1982 to September, 1982). The 83 cases they reported included 19 females. Interestingly, all the female Koro cases in this particular sample believed it was their breasts that were affected in some way. More specifically, Dr. Dutta and his team reported that:

“9 out of 19 female cases (47.3%) suffered from genital symptoms in form of shrinkage or pull of the breast. Not a single female complained of labial shrinkage. 12 out of 19 cases (69.1%) reported retrosternal pain and other anxiety symptoms subsequently leading to dissociation of varying degree and duration”.

In 1994, Dr. Arabinda Chowdhury (who has written lots of papers on the topic of Koro) published a paper in the journal Transcultural Psychiatry comprising an analysis of 48 cases of female Koro (based on a population of women that claimed to have Koro in an Indian epidemic in the North Bengal region). In females, Dr. Chowdhury noted that “the cardinal symptom is the perception of retraction or shrinkage of nipple or breast mass into the chest cavity or of labia into the abdomen with acute fear of either imminent death or sexual invalidism”. This was the first paper in the world literature to explore the detailed clinical characteristics of Koro in females. Before examining the individual cases, Dr. Chowdhury examined the gender distribution in seven Koro epidemics. The following statistics were reported: Singapore (1969; 469 cases, 15 female), Thailand (1978; 350 cases, 12 female), Indonesia (1978; 13 cases, 2 female), India (1982; 83 cases, 19 female), India (1985; 31 cases, 13 female), India (1988; 405 cases, 48 female) and China (1988; 232 cases, 37 female).

Dr. Chowdhury reported that of the 48 female cases (aged 8 to 54 years), the mean age was nearly 24 years. In relation to Koro, 56% reported retracting nipples (both breasts in all but two cases), 13% reported a flattening of their breasts, 8% reported a retraction in both breasts, 8% reported a pricking sensation in both breasts, 8% reported retraction of the labia, and 5% reported vaginal pain.

It appears that in the same that penis size seems to be a near-universal concern and/or obsession of men, women also share a similar fear, but with different sexual body parts (i.e., vulvas, breasts, and nipples). All of these body parts in males and females (i.e., penis, scrotum, breasts, nipples) are physiologically capable of changing size not only in relation to sexual arousal but also from other non-sexual factors (temperature and climate change, anxiety, depression, stress, fear, illness, and/or psychoactive drug ingestion/intoxication).

One literature review of 84 case reports of Koro (and Koro-like disorders) published in a 2008 issue of the German Journal of Psychiatry by Dr. Petra Garlipp (Hannover Medical School Germany) concluded that there were two unifying features of the case reports cited in the clinical literature. These were (i) the diversity in relation to the clinical picture, the underlying mental disorder, the treatment approach and their classification and nomenclature chosen, and (ii) the symptom of fear.

In response to Dr. Garlipp’s paper, Dr. Arabinda Chowdhury noted that by only using published case studies, female Koro was hardly discussed (because most data about female Koro comes from data collected during Koro epidemics rather than case study interview data). why the review had been so biased towards males. Based on his own research, Dr. Chowdhury wrote that there were at least 146 female Koro case reports from seven epidemics in the years 1969 to 1988. He believed the large number of cases involving women offered many interesting clinical issues in the female expression of Koro, which should have been included in Garlipp’s review. His view was that the differences between male and female Koro in relation to psychodynamics, presentation and associated clinical features of Koro would have made Garlipp’s paper “more interesting”. However, Dr. Chowdhury’s paper didn’t mention what these differences were. Maybe there is not the data to do this. Although it is known that episodes of female Koro can endure for weeks or months, the origin of female anxiety over the absorption of their sex organs is at present unclear.

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

Further reading

Bartholomew, R. (2000). Exotic Deviance: Medicalizing Cultural Idioms from Strangeness to Illness. Boulder: University of Colorado Press.

Bartholomew, R. (2008). Penis panics. In R. Heiner (Ed.), Deviance across cultures (pp. 79–85). New York: Oxford University Press.

Chowdhury, A.N. (1994). Koro in females: An analysis of 48 cases. Transcultural Psychiatry, 31, 369-380.

Chowdhury, A.N. (2008). Ethnomedical concept of heat and cold in Koro: study from Indian patients. World Cultural Psychiatry Research Review, July, 146-158.

Chowdhury, A.N. (2008). Cultural Koro and Koro-Like Symptom (KLS). German Journal of Psychiatry, 11, 81-82

Cheng, S.T. (1997). Epidemic Genital Retraction Syndrome: Environmental and personal risk factors in Southern China. Journal of Psychology and Human Sexuality, 9, 57-70.

Dutta, D., Phookan, H.R. & Das, P.D. (1982). The Koro epidemic in Lower Assam. Indian Journal of Psychiatry, 24, 370-374.

Dzokoto, V.A. & Adams, G. (2005). Understanding genital-shrinking epidemics in West Africa: Koro, Juju, or mass psychogenic illness? Culture, Medicine and Psychiatry, 29,53-78.

Garlipp, P. (2008). Koro – A culture-bound phenomenon intercultural psychiatric implications. German Journal of Psychiatry, 11, 21-28.

Jilek, W.G. (1986). Epidemic of “Genital Shrinking” (Koro): Historical review and report of a recent outbreak in south China. Curare, 9, 269-282.

Kar, N. (2005). Chronic koro-like symptoms – two case reports. BMC Psychiatry, 5, 34 (doi:10.1186/1471-244X-5-34).

Kovács, A. & Osváth P. (1988). Genital retraction syndrome in a Korean woman. A case of Koro in Hungary. Psychopathology, 31, 220-224.

Lehman, H. E. (1980). Unusual Psychiatric disorders. In: A.M. Freedman, H.I. Kaplan & B.J. Sadock (Eds.). Comprehensive Textbook of Psychiatry (Third Edition, Vol. II). Baltimore: Williams and Wilkins.

Palthe, P.M. (1936). Psychiatry and Neurology in the Tropics. In: C.D. de Langen and A. Lichtenstein (Eds.), A Clinical Textbook of Tropical Medicine (pp. 525-547). Batavia: G. Kolff and Company.

Phillips, K. (2004). Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry, 3, 12-17.

Tattoo’s company: A beginner’s guide to stigmatophilia

One of the less researched sexual behaviours is stigmatophilia. It is a sexual paraphilia in which an individual derives sexual pleasure and arousal from a partner that is marked in some way. Traditional definitions of stigmatophilia referred to such individuals being sexually aroused by scarring but more recent formulations of stigmatophilia includes those who are sexually aroused by tattoos and piercings (i.e., body modifications especially relating to genitals and/or nipples). According to Professor John Money, stigmatophilia can also refer to the reciprocal condition where the sexual focus is on the person who has the scars, tattoos, and/or piercings. Other even more recent definitions claim that a stigmatophile is “a person with this fetish is sexually aroused by body piercing and tattooing but not ear piercing” (Gay Slang Dictionary).

Stigmatophilia is one of many different eligibility (also called stigmatic) types of paraphilia. In his 2009 book Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices, Dr Anil Aggrawal (Maulana Azad Medical College, New Delhi, India) writes that the strategy adopted by those who have eligibility paraphilias is that:

“To protect the saintly love from sinful lust is to chose his partner who is so base so unqualified, so depraved that he or she is simply unable or ineligible to compete with the saint, their partner must become a pagan infidel or an erotic heathen. The partner must not appear to be a proper or likeable person. This is done by choosing a partner who is very diminutive or towering in stature fat or skinny very young (paedophilia) or very old (gerontophilia), disfigured, deformed (dysmorphophilia), crippled, stigmatized  (stigmatophilia), even an amputee (acrotomophilia) In extreme cases, the paraphilic wants his partner to be from a different species (zoophilia) or dead (necrophilia), or even a dead specimen of a different species (necrozoophilia). Sometimes the paraphilic may want even himself to be deformed (he is also one of the partners in love making). This desire is reflected in paraphilias like apotemnophilia in which the paraphiliac desires to have his own healthy appendages (limb, digit, or genitals) amputated”

In previous blogs on various fetishes and paraphilia, I have written about a study led by Dr G. Scorolli (University of Bologna, Italy) on the relative prevalence of different fetishes using online fetish forum data. It was estimated (very conservatively in the authors’ opinion), that their sample size comprised at least 5000 fetishists (but was likely to be a lot more). They reported that some of the sites featured references to stigmatophilia (including body modification). This category made up a small minority of all online fetishes (4%).

Brenda Love noted in her book Encyclopedia of Unusual Sex Practices that tattooing was brought back to Europe by sailors (who had become fascinated by this art from). Consequently, Professor Christine Braunberger (Onondaga Community College, Syracuse, US) wrote a paper for the online journal Genders in 2000 examining the cultural and sexual significance of sailor’s tattoos. She asserted that tattoos are “erotic and potentially fetishistic from an experiential level” and that they “also visually mark a conflation of nationalism and sexuality”. She also argues that navy tattoos depicting women illustrate a “heterofamilial fetish of national culture” that encourages tattoos to be viewed as marks of familial desire (in fact she tries to argue that such tattoos are “symbolic surrogates” for wives and girlfriends). These tattoos often contained “naked women, women draped in flags or other patriotic regalia, dancing girls, and the popular ‘Lady Luck’ or ‘Man’s Ruin’ images in which a female form was surrounded by booze bottles, dice and cards”.

While researching this blog, I came across this confession from a male with a tattoo fetish:

Now I almost 30 and I am working on a complete tattoo bodysuit. I still am turned on by the idea of being totally covered in ink. I am almost there and I only have a few blank spots left. Before I get more I really want to understand this. I was never abused. I don’t hate my body. I have lots of confidence and there is no ‘thing’ in my past that I can think of that would make me this way. It also isn’t a rebellion thing because my family is cool with it and so is my job. I just love having ink, I love getting it, I love the pain, I love the healing, I love looking at it and I love when women touch it. Why am I this way? I am a normal guy and I have a normal sex life, normal relationships etc. BUT when I masturbate I usually don’t need porn. I just picture my entire body being covered in tattoos…Sometimes I look at my own ink in the mirror etc. The more I get the happier I am. I just want to know, what would cause this? Where do fetishes come from? Are they bad if they don’t interfere with your life?”

For me, this quote neatly sums up the fact that this person’s fetish is unproblematic but is key to his sexual arousal. He also displays what Dr. Katherine Irwin writing in a 2003 issue of Sociological Spectrum might call a ‘positive deviant’. Her paper examined two groups within the most elite realm of tattooing (i.e., tattoo collectors and tattooists), and identified how they use both positive and negative deviant attributes to maintain a privileged status on the fringe of society. Whilst not concentrating on the fetishistic element, many of her observations may apply to those with tattoo fetishes. However, she does note that:

“Tattooists foster tastes for macabre and bizarre objects. Such products as fetish magazines, medical books depicting congenital abnormalities, and fringe films and art are highly coveted by members of the elite world of tattooing”

Comparatively little is known about intimate body piercing or its relevance to human behaviour. Dr. Charles Moser and his colleagues published a paper in a 1993 issue of Journal of Psychology and Human Sexuality on reasons for nipple piercing among 362 participants. The main reasons for nipple piercing were sexual responsiveness and sexual interest. More recently, Professor Carol Caliendo and her colleagues carried out some research on intimate body piercings that they published in a 2005 issue of the Journal of Advanced Nursing. They surveyed a convenience sample of intimately pierced individuals (63 women and 83 men) across 29 US states. Participants reported having nipple piercings (43%), genital piercings (25%) or both types (32%). Compared to the general US population those with sexual piercings were significantly younger, less ethnically diverse, better educated, less likely to be married, more often homosexual or bisexual and they initiated sexual activity at a younger age. The average age for first nipple piercing was 25 years, and for genital piercing was 27 years. Their reasons for getting the piercings were uniqueness, self-expression and sexual expression.

Arguably, one of the best papers on motivations for tattooing and body piercing was published by Dr. Silke Wohlrab and colleagues (University of Goettingen, Germany) in a 2007 issue of the journal Body Image. They established ten broad motivational categories, comprising motivations for getting tattooed and body pierced. This they hoped would serve as a reference in future research in the area. The ten categories were: (i) beauty, art, and fashion, (ii) individuality, (iii) personal narratives, (iv) physical endurance, (v) group affiliations and commitment, (vi) resistance, (vii) spirituality and cultural tradition, (viii) addiction, (ix) sexual motivations, and (x) no specific reasons (e.g., doing it on impulse, or doing it while intoxicated). In relation to sexual motivations, the authors noted that:

“Nipple and genital piercings are quite common and serve as decoration, but also for direct sexual stimulation. Expressing sexual affectations or emphasizing their own sexuality through tattooing and body piercing are also common motivations”.

Clearly, the research that is beginning to be carried out in recent years doesn’t really make specific reference to stigmatophilia as it tends to concentrate on specific types of self-inflicted body modification (particularly tattooing and body piercing) rather than those who have been left with inflicted wounds from third parties (e.g., facial scarring).

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

Further reading

Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.

Braunberger, C. (2000). Sutures of Ink: 
National (Dis)Identification and the Seaman’s Tattoo. Genders (Online Journal). Located at: http://www.genders.org/g31/g31_braunberger.html

Caliendo, C., Armstrong, M.L. & Roberts A.E. (2005). Self-reported characteristics of women and men with intimate body piercings. Journal of Advanced Nursing, 49, 474–484

Irwin, K. (2003). Saints and sinners: elite tattoo collectors and tattooists as positive and negative deviants. Sociological Spectrum, 23, 27-57.

Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.

Meyer D. (2000) Body piercing: old traditions creating new challenges. Journal of Emergency Nursing, 26, 612–614.

Moser C., Lee J. & Christensen P. (1993) Nipple piercing: an exploratory-descriptive study. Journal of Psychology and Human Sexuality, 6(2), 51–61.

Money, J. (1984). Paraphilias: Phenomenology and classification. American Journal of Psychotherapy, 38, 164-78.

Scorolli, C., Ghirlanda, S., Enquist, M., Zattoni, S. & Jannini, E.A. (2007). Relative prevalence of different fetishes. International Journal of Impotence Research, 19, 432-437.

Wohlrab, S., Stahl, J. & Kappeler, P.M. (2007). Modifying the body: Motivations for getting tattooed and pierced. Body Image, 4, 87-95

Genital on my mind: A beginner’s guide to Koro

Koro is a culture-bound syndrome found primarily in Asian regions (e.g., China, Singapore, Thailand, India) and has been documented for thousands of years in those particular cultures. In essence, Koro refers to a kind of “genital hysteria” with “terror stricken” males believing that that their genitals are shriveling, shrinking up, retracting into the abdomen and/or disappearing, and that this ultimately leads to death (a so-called ‘genital retraction syndrome). The word ‘Koro’ is of Malayan-Indonesian origin and means ‘tortoise’ (presumably used to highlight the similarity between the retracting head and wrinkled neck of a tortoise and the belief that the male penis is retracting inside the body). Writing in a 1997 issue of the Journal of Psychology and Human Sexuality, Dr. J.T. Cheng noted of Koro that it:

“Is best perceived as a social malady supported by cultural myths which tend to affect young people who are deprived of proper sex information to explain their physical development”.

Various academic papers and book chapters (such as one by Dr. R. Bartholomew in 2008) claim that affected individuals take extreme measures to suspend the condition (e.g., placing clamps, clothes pegs, rubber bands, and/or tying string around their penis to stop it retracting. In some cases, men had family members physically hold onto their penis until they receive “treatment” from local healers). According to Dr. Bartholomew episodes of Koro can last for weeks or months and affect thousands of men. The condition has been recorded in Chinese academic texts going back to the 1800s. There also appear to be different cultural variants of Koro-like syndromes. For instance, in West Africa, some Nigerian men actually believe that their penises have been stolen.

Sometimes the condition occurs en masse such as the “penis panics” that have been documented in countries such as China, India and Singapore. For instance, a well documented Koro panic occurred in Singapore during the Autumn of 1967. The regional hospitals were inundated with hundreds of men demanding penile treatment (and thinking they would die without treatment). During this particular Koro epidemic, it was thought that the cause was eating pork (from pigs that had been inoculated for swine fever).

In Northeast Thailand in November/December 1976, around 2,000 men thought that their penises were shrinking. Another ‘penis panic’ was reported more recently in the Guangdong province of China. For over a year in 1984-1985 around 5,000 people living in the region believed they had Koro. Other Chinese Koro epidemics have occurred frequently on Hainan Island in the China Sea and also in the nearby Leizhou Peninsula in Southern China. These Koro epidemics suggest that various socio-cultural factors are influencing people’s beliefs about the condition. However, on a socio-demographic level, the psychological literature on Koro suggests that individuals that are most likely to be affected are those living in rural regions where there is poor education.

Most Koro epidemics are among adult males but isolated “collective occurrences” of Koro among children have also been reported in the Chinese Sichuang Province in a 1993 issue of the Chinese Journal of Mental Health. More recently, in a December 2010 issue of World Cultural Psychiatry Research Review, Dr. Li Jie (Guangzhou Psychiatric Hospital, China) reported a Koro endemic among 64 schoolboys in the Fuhu village of Guangdong. The contributing factors for the mass occurrence were reported as being (i) the familiarity with koro in the community, (ii) stress due to their studies, and (iii) a misleading warning and instruction from the school principal.

The interesting thing about Koro is that the penis is a body part that naturally swells and shrinks in response not only in relation to sexual arousal but also in response to temperature and climate changes, depression, anxiety, stress, fear, illness, and/or psychoactive drug ingestion. These real reasons for penile shrinkage when combined within cultures that accept and to some extent ‘authenticate’ the existence of Koro, can lead (in some instances and circumstances) to the psychosocial panics documented in particular regions or countries. Koro has also been is associated with various and specific cultural beliefs. One such set of beliefs is that unhealthy or abnormal sexual behaviours (e.g., masturbation, wet dreams, sex with prostitutes, etc.) disturb the “yin/yang equilibrium” that allegedly exists within a husband and wife’s sex life and causes Koro.

Some psychologists have also speculated that Koro may be psychologically related to body dysmorphic disorder. However, Dr Katharine Phillips (Warren Alpert Medical School of Brown University, USA), an expert in BDD and writing in a 2004 issue of World Psychiatry notes that although Koro has similarities to BDD, Koro differs from BDD by (i) its normally brief duration of a few weeks or months rather than years, (ii) different associated features (e.g., the belief by the sufferer that they are going to die), (iii) response to reassurance, and (iv) occasional epidemic occurrences (something that never happens with more traditional BDD occurrences).

However, there were a couple of case reports published by Dr. Nilamadhab Kar (Wolverhampton Primary Care Trust, UK) in BMC Psychiatry arguing that Koro is not always an acute, brief lasting illness. Dr. Kar’s paper reported two cases of males with with koro-like symptoms from East India (characterized by excessive anxiety and a belief that their genitals were shrinking) had lasted over ten years and concluded that in some cases, there is the possibility of a chronic form of Koro syndrome.

One literature review of 84 case reports of Koro (and Koro-like disorders) published in a 2008 issue of the German Journal of Psychiatry by Dr. Petra Garlipp (Hannover Medical School Germany) concluded that there were two unifying features of the case reports cited in the clinical literature. These were (i) the diversity in relation to the clinical picture, the underlying mental disorder, the treatment approach and their classification and nomenclature chosen, and (ii) the symptom of fear. Based on her comprehensive review, Dr. Garlipp collated all known etiological and predisposing factors. The two main sets of factors implicated in Koro and Koro-like disorders were (i) psychosexual conflicts, (ii) personality factors, (iii) cultural beliefs, (iv) sexual conflicts, and (v) guilt feelings, often caused by religious background. She also reported that factors implicated with commonly shared beliefs included (i) geographic seclusion, (ii) mostly young poorly educated men susceptible to superstitious beliefs, (iii) suggestion, (iv) belief in the concept of Koro, (v) immature personality and lack of sexual confidence, (vi) previous knowledge of Koro, (vii) poor body image, (viii) history of venereal disease, and (ix) preoccupation with genitals.

Dr Garlipp also concluded that treatment with antidepressants and antipsychotics has – in the main – been successful. She also concluded that:

“Koro in its original sense is an Asian socio-cultural phenomenon. Its clinical picture has been controversially discussed in psychiatric literature but could be best described as a kind of panic disorder with the leading symptom of fear projected to the genitals. Yet, it is questionable whether this phenomenon can be put into a Western dominated classification of psychiatric diseases, as the socio-cultural roots are not adequately appreciated…All clinical phenomena presenting themselves in a wider sense as genital retraction syndromes with the leading symptom of fear should be named as such: genital retraction syndromes. All other nomenclatures, especially Koro- like syndrome, secondary Koro etc., should be dismissed as misleading”.

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

Further reading

Adeniran, R.A. & Jones, J.R. (1994). Koro: Culture-bound disorder or universal symptom? British Journal of Psychiatry, 164, 559- 561.

Bartholomew, R. (2008). Penis panics. In R. Heiner (Ed.), Deviance across cultures (pp. 79–85). New York: Oxford University Press.

Cheng, S.T. (1997). Epidemic Genital Retraction Syndrome: Environmental and personal risk factors in Southern China. Journal of Psychology and Human Sexuality, 9, 57-70.

Garlipp, P. (2008). Koro – A culture-bound phenomenon intercultural psychiatric implications. German Journal of Psychiatry, 11, 21-28.

Jie, L. (2010). Koro endemic among school children in Guangdong, China. World Cultural Psychiatry Research Review, December, 102-105.

Kar, N. (2005). Chronic koro-like symptoms – two case reports. BMC Psychiatry, 5, 34 (doi:10.1186/1471-244X-5-34).

Phillips, K. (2004). Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry, 3, 12-17.

Tseng, W.S., Kan-Ming, M., Hsu, J., Li-Shuen, L., Li-Wah. O., Guo-Qian, C., & Da-Wie J. (1988). A sociocultural study of Koro epidemics in Guangdong, China. American Journal of Psychiatry, 145, 1538-1543.

Tseng, W.S., Kan-Ming, M., Li-Shuen, L., Guo-Qian, C., Li- Wah, O., & Hong-Bo, Z. (1992). Koro epidemics in Guangdong, China. A questionnaire survey. Journal of Nervous and Mental Diseases, 180, 117-123.

Zhang, J.K. & Zhu, M.X. (1993). Three cases report of children Koro. [Chinese] Chinese Journal of Mental Health, 7, 40-41.

Snot machines: Can nose picking be an obsessive-compulsive disorder?

How does it make you feel when you see someone picking their nose and then eating what they have found? Disgust? Contempt? Amused? Whatever your reaction it’s unlikely to be neutral. Nose-picking on the face of it (no pun intended) is probably one of the most under-researched activities given the fact that it is an every day activity for many people and appears to be a universal activity across cultures. It is believed that across many cultures, nose-picking belongs to a set of behaviours considered a private act (such as burping, breaking wind, urinating and defecating).

There is also an element of the activity being mildly taboo despite it being so prevalent. The definition I’ve come across most often in non-academic journals (i.e., on the internet) is that nose-picking is the act of extracting dried nasal mucus (snot) and/or foreign bodies with a finger from the nose. There have been anecdotal reports that people engaging in some sorts of activity appear to be more likely to pick their noses in seemingly public places (drivers stopping at traffic lights or junctions being one example I came across in a blog on nose-picking). But what does the empirical research say about nose-picking?

A paper published on nose picking in the Journal of Clinical Psychiatry (JCP) in the mid-1990s by James Jefferson and Trent Thompson (University of Wisconsin Medical School, USA), reported that 91% of people surveyed in Wisconsin were current nose-pickers (n=254). Three-quarters of the sample thought that “almost everyone else does it”. Five respondents (2%) said they picked their nose for enjoyment, and one person said they found picking their nose sexually stimulating. Two respondents reported that their nose-picking had led to a perforation of the nasal septum. Another two people in the study said they were excessive nose-pickers (with one respondent spending 15-30 minutes a day picking their nose, and the other one claiming they spent 1-2 hours a day picking their nose). It is possible that these two excessive nose-pickers may have been suffering from rhinotellexomania that is characterized as a constant, repetitive and/or pathological picking of the nose and viewed by some as a form of undiagnosed obsessive-compulsive disorder. They also reported the incidence of other associated behaviours. A total of 25% picked their cuticles, 20% picked at skin, 18% bit their fingernails (18%), and 6% pulled out their hair.

More recently (and taking their lead from the earlier study published in the 1995 JCP paper), two psychiatrists – Dr Chittaranjan Andrade and Dr B.S. Srihari (National Institute of Mental Health and Neurosciences in Bangalore, India) – published a study on rhinotillexomania among 200 adolescents in the Journal of Clinical Psychiatry. They reported that adolescents pick their noses about four times a day. They started from the position that any human activity – if carried to excess – could potentially be viewed as a psychiatric disorder. They made reference to earlier case studies in the literature which seemed to indicate that excessive nose-pickers written about affected were psychotic (e.g., Gigliotti & Waring, 1968 – 61-year-old woman with extensive self-mutilation of the inner nose such that a nasal prosthesis and complete upper denture had to be constructed; Akhtar & Hastings 1978 – a 36-year-old male compulsive nose picker, who had life-threatening nosebleeds as a result of excessive nose picking). A more recent case study published by Ronald Caruso and colleagues (State University of New York Health Science Center at Syracuse, USA) presented a case of rhinotillexomania in a woman. They noted:

“Chronic self-mutilation resulting in the loss of body parts is characteristically seen in schizophrenic patients. Such patients can have delusions of parasitic infestation of body parts, may believe the body part to be encumbered by foreign bodies, or may view the body part as no longer a part of themselves. Such behavior, however, may also be manifested by persons who are severely obsessive-compulsive or malingerers… A 53-year-old right-handed woman related a history of compulsive nose picking (rhinotillexomania) of the right nasal cavity since age 10. She could not control her compulsion, which involved removing recurrent intranasal crusts. This condition persisted while in the care of a psychiatrist… Therapy was instituted in an effort to disrupt the cycle of digital trauma, mucus production, and crusting. This included behavior modification and supportive rhinologic care with nasal spray, crust suction, and medication. Early follow-up showed improvement”

They noted that the psychiatric literature has recognized that “rhinotillexomania is a common, benign habit in children and adults” but that in rare cases it can become a serious affliction advancing to significant self-injury.

Andrade and Srihari’s main findings were that (i) 96% had picked their nose, (ii) 80% used their fingers to pick their nose, (iii) half picked their noses four or more times a day, (iv) 7% picked their noses 20 or more times a day, (v) over 50% picked their noses to unclog nasal passages, to relieve discomfort, or to relieve itching, (vi) 11% picked their nose for cosmetic reasons, and (vii) 11% picked their noses for pleasure. They also observed that based on their sample, nose-picking practices were the same across all social classes.

Much less is known about the act of eating the extracted contents directly from the nose (known as mucophagy). A case report dating back to 1966 by Sidney Tacharow on copraphagia (eating faeces) also examined the eating of other bodily substances. The author claimed that the reason people ate nasal debris was because they found it “tasty”. In the study by Jefferson and Thompson, it was reported that 8% of their respondent admitted to eating their nasal content (but there was no reason given as to why they did it). The study by Andrade and Srihari’s reported that 4.5% of their participants ate their nasal debris.

I did a literature search looking for academic papers on snot eating snot and only came up with only one by Maria Jesus Portalain – a 2007 book chapter entitled “Eating snot – Socially unacceptable but common: Why?” in an edited book collection called “Consuming the inedible: neglected dimensions of food choice” (which also had chapters on topics such as geophagia and cannibalism). She questioned to what extent snot could be classed as edible? As she noted, the composition of snot was water (95%), glycoprotein (2%), other proteins (1%), immunoglobin (1%), lactoferrin (trace), lysozyme (trace), and lipids (trace). She observed that the eating of snot could be studied from a number of different scientific disciplines but it was only psychologists that had ever studied it. She argued that nasal mucus was socially accepted but eating it was not. In preparation of writing her chapter, she asked a small group of adults if they ate they ate their snot and they all vehemently said they didn’t. She then asked the same people if when they kissed their partner they put their tongue in their partner’s mouths. It was a ‘yes’ all around. She then posed the question why consuming your partner’s saliva was better than eating your own snot?

In February 2008, an Austrian lung specialist (Dr Friedrich Bischinger) was reported as saying that picking your nose and eating it was good for you. He claimed that people who pick their noses with their fingers were healthy, happier and probably better in tune with their bodies than those who didn’t. He was reported as saying:

“With the finger you can get to places you just can’t reach with a handkerchief, keeping your nose far cleaner. And eating the dry remains of what you pull out is a great way of strengthening the body’s immune system. Medically it makes great sense and is a perfectly natural thing to do. In terms of the immune system the nose is a filter in which a great deal of bacteria are collected, and when this mixture arrives in the intestines it works just like a medicine. Modern medicine is constantly trying to do the same thing through far more complicated methods. People who pick their nose and eat it get a natural boost to their immune system for free. I would recommend a new approach where children are encouraged to pick their nose. It is a completely natural response and medically a good idea as well. Children happily pick their noses, yet by the time they have become adults they have stopped under pressure from a society that has branded it disgusting and anti social”

He went on to suggest that if anyone was worried about what other people think, they should pick their noses privately if they want to get the benefits. Despite the alleged benefits of nose picking I will leave you with a 2002 case reported by Dr L.F. Fontenelle and colleagues (Federal University of Rio de Janeiro, Brazil) who described a person with rhinotillexomania that may have been secondary to body dysmorphic disorder (BDD). The man in question developed a self-destructive habit of pulling and severely scraping hairs and nasal debris out of his nose. The authors proposed the term rhinotrichotillomania to emphasize the overlapping between trichotillomania (compulsive hair pulling) and rhinotillexomania (compulsive nose picking). The main motivation behind the man’s actions was a distressing preoccupation with an imaginary defect in his appearance (a core characteristic of BDD). The authors suggested that certain features of trichotillomania, rhinotillexomania, and BDD may in some circumstances overlap and produce serious clinical consequences.

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

Further reading

Akhtar, S. & Hastings, B.W. (1978). Life threatening self-mutilation of the nose. Journal of Clinical Psychiatry, 39, 676-677.

Andrade, C. & Srihari, B.S. (2001). A preliminary survey of rhinotillexomania in an adolescent sample. Journal of Clinical Psychiatry, 62, 426-31.

Caruso, R.D. Sherry, R.G., Rosenbaum, A.E., Joy, S.E., Chang, J.K. & Sanford, D.M. (1997). Self-induced ethmoidectomy from rhinotillexomania. American Journal of Neuroradiology 18, 1949-1950.

Fontenelle, L.F. Mendlowicz, M.V., Mussi, T.C., Marques, C. & Versiani, M. (2002). The man with the purple nostrils: a case of rhinotrichotillomania secondary to body dysmorphic disorder. Acta Psychiatrica Scandinavica, 106, 464-466.

Gigliotti, R. & Waring, H.G. (1968). Self-inflicted destruction of nose and palate: Report of case. Journal of the American Dental Association, 76, 593-596.

Jefferson, J.W. & Thompson, T.D. (1995). Rhinotillexomania: Psychiatric disorder of habit?  Journal of Clinical Psychology, 56 (2), 56-59.

Portalain, M.J. (2007). Eating snot – Socially unacceptable but common: Why?” In J. MacClancy, J. Henry & H. Macbeth (Eds.), Consuming the inedible: neglected dimensions of food choice. New York: Berghahn Books.

Tarachow, S. (1966). Coprophagia and allied phenomena. Journal of the American Psychoanalytic Association, 14, 685-699.

Never mind the anabolics! A brief overview of body building dependence

In a previous blog, I briefly examined exercise addiction and its relationship with eating disorders. A recent review of 11 different addictive behaviours – that I co-wrote with Dr Steve Sussman and Nadra Lisha (University of Southern California) – estimated the prevalence of exercise addiction in the general population to be close to 3%. This figure is even higher in research I have carried out into certain sub-groups of people such as ultra-marathon runners and sport science students. In this article, I briefly examine exercise dependence among another particular sub-group of people that may experience elevated rates of exercise addiction and dependence – namely, body builders.

Exercise dependence has been defined by Dr Heather Hausenblas (University of Florida, USA) and Dr Danielle Symons Downs (Pennsylvania State University, USA) as ‘‘a craving for exercise that results in uncontrollable excessive physical activity and manifests in physiological symptoms, psychological symptoms, or both’’. However, in the course of assessment of exercise addiction, several incongruent results have emerged. The most likely reason may be connected to two issues, namely (i) the instrument used in assessment of exercise addiction/dependence, and (ii) the target population studied (including the fact that sample sizes are typically very small compared with other studies of other potentially addictive behaviours).

One of the more interesting observations surrounding exercise addiction and dependence among body builders concerns their thoughts around body image and whether this may play a role in the development of the addiction. From a body image perspective, researchers have suggested that males in western society have developed significant body concerns that cause them to generate a ‘drive for muscularity’ to meet a perceived high societal standard for a muscular physique. Not all bodybuilders engage in the activity purely to develop a hyper-muscular physique. However, those who are body building to overcome weaknesses in self-esteem and body image, may be more susceptible to excessive exercise routines and obsessive eating disturbances. However, to date, the research findings are somewhat inconclusive.

There are several instruments available for assessing exercise addiction. However, they are either rarely adopted in research or are aimed at a specific form of physical activity, such as bodybuilding. For instance, the Bodybuilding Dependency Scale (BDS) was developed by Dr Dave Smith (University of Chester) specifically to assess compulsive training in bodybuilding and weightlifting and has been validated in a number of his subsequent studies. The BDS comprises three sub-scales: (i) social dependence (the need to be in the gym), (ii) training dependence (compulsion to train), and (iii) mastery dependence (the need to control training).

Dr Treven Pickett and colleagues at the Virginia Consortium Programme (Virginia Beach, USA) reported that ‘competitive bodybuilders’ and ‘non-competitive weight trainers’ were both more ‘appearance-invested’ than active athletic controls that didn’t lift weights. Other research studies have found bodybuilders have significantly higher concerns regarding the size and shape of their physique than power lifters. However, none of these studies have utilized validated ‘desire for masculinity’ measures. Furthermore, few studies have examined the relationship between exercise dependence and desire for masculinity in male exercisers although correlations have been found between exercise dependence with muscle-oriented body image and muscularity-related behaviors on the Drive for Muscularity Scale.

Up until recently, it was unclear whether there were any differences in the prevalence of exercise dependence among different types of weight lifters (such as bodybuilders, power lifters, and fitness lifters) even though there is some anecdotal evidence suggesting that these distinct groups have different motives for weight lifting. One of the best studies examining this issue was recently been carried out by Dr Bruce Hale and colleagues (Kinesiology Department, Penn State-Berks, USA). They examined 146 weight lifters (59 bodybuilders, 47 power lifters, and 40 fitness lifters) on the Exercise Dependence Scale (EDS), the Bodybuilding Dependence Scale (BDS), and the Drive for Muscularity Scale (DMS). Results showed that bodybuilders and power lifters were significantly higher than fitness lifters on EDS and BDS scales. In contrast, power lifters were found to be significantly higher on DMS than bodybuilders. They claim that their results suggest that exercise dependence may be directly related to the drive for muscularity.

Just to complicate things even further, there are some recent studies that suggest muscle dysmorphia – a pathological preoccupation with muscularity and related to body dysmorphic disorder – may also be linked to exercise dependence (but that will have to wait for another blog!).

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

Further reading

Allegre, B., Souville, M., Therme, P. & Griffiths, M.D. (2006). Definitions and measures of exercise dependence, Addiction Research and Theory, 14, 631-646.

Allegre, B., Therme, P. & Griffiths, M.D. (2007). Individual factors and the context of physical activity in exercise dependence: A prospective study of ‘ultra-marathoners’. International Journal of Mental Health and Addiction, 5, 233-243.

Berczik, K., Szabó, A., Griffiths, M.D., Kurimay, T., Kun, B. & Demetrovics, Z. (2012). Exercise addiction: symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, DOI: 10.3109/10826084.2011.639120.

Blaydon, M.J., Lindner, K.J. & Kerr, J.H. (2002). Meta-motivational characteristics of eating-disordered and exercise-dependent triathletes: An application of reversal theory. Psychology of Sport and Exercise, 3, 223-236.

Hale, B.D, Roth, A.D., DeLong, R.E. & Briggs, M.S. (2010). Exercise dependence and the drive for muscularity in male bodybuilders, power lifters, and fitness lifters. Body Image, 7, 234-239.

Chittester, N.I., & Hausenblas, H.A. (2009). Correlates of the drive for muscularity: The role of anthropometric measures and psychological factors. Journal of Health Psychology, 14, 872-877.

Hausenblas, H.A., & Downs, D. S. (2002a). Exercise dependence: A systematic review. Psychology of Sport and Exercise, 3(2), 89-123.

McCreary, D.R., Sasse, D.K., Saucier, D. & Dorsch, K.D. (2004). Measuring the drive for muscularity: Factorial validity of the Drive for Muscularity Scale in men and women. Psychology of Men and Masculinity, 5, 49-58.

Pickett, T.C., Lewis, R.J. & Cash, T.F. (2005). Men, muscles, and body image: Comparisons of competitive bodybuilders, weight trainers, and athletically active controls. British Journal of Sports Medicine, 39, 217-222.

Smith, D.K., & Hale, B.D. (2004). Validity and factor structure of the bodybuilding dependence scale. British Journal of Sports Medicine, 38, 177-181.

Smith, D.K., & Hale, B.D. (2005). Exercise-dependence in body- builders: Antecedents and reliability of measurement. Journal of Sports Medicine and Physical Fitness, 45, 401-408.

Smith, D.K., Hale, B.D., & Collins, D. (1998). Measurement of exercise dependence in bodybuilders. Journal of Sports Medicine and Physical Fitness, 38, 66-74.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Szabo, A. & Griffiths, M.D. (2007). Exercise addiction in British sport science students. International Journal of Mental Health and Addiction, 5, 25-28.

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