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What’s bugging you? A beginner’s guide to Ekbom’s syndrome
It was only a few months ago that I watched the 2006 film Bug for the very first time. Directed by William Friedkin, it tells the story of a mentally ill drifter called Peter Evans (with a great performance by Michael Shannon). Evans ends up having a sexual relationship with Agnes White, a bisexual alcoholic junkie (played surprisingly well by Ashley Judd). During the film, Peter confides in Agnes his belief that he has a colony of microscopic bugs infested one of his molar teeth (and then in one ‘memorable’ scene starts pulling his own teeth out). Evans’ paranoia becomes increasingly erratic and becomes a shared belief with White (who also comes to believe that they are both infested with microscopic bugs; this sharing of a delusional belief is known as a ‘folie à deux’ [French for ‘a madness shared by two people’, a shared psychosis] and would make a good blog topic). However, today’s blog focuses on imagined bug infestation (i.e., delusional parasitosis) that is known in psychological and psychiatric terms as Ekbom’s syndrome (named after the Swedish neurologist Karl Ekbom who first described the condition in a number of published papers in the late 1930s).
As you have probably gathered from my quick film synopsis above, Ekbom’s syndrome (ES) is a type of psychosis in which sufferers have a vehement delusional belief that they are infested with parasites that those affected describe as bugs or insects crawling around under their skin (when in reality they simply do not exist). I ought to add that the characters in Bug also appeared to be suffering from ‘delusory cleptoparasitosis’ (DC) another type of insect psychosis in which the sufferer thinks the place where they live is infested with parasites (rather than from within their body). As a consequence, both ES and DC sufferers are more likely to seek the help of skin specialists (e.g., dermatologists) and insect specialists (e.g., pest control, entomologists) than psychologists.
In essence, ES is a tactile hallucination and is also known as ‘formication’ (which is the word that describes the feeling of insects crawling and/or burrowing underneath the skin’s surface. Formication is also one form of parasthaesia (of which other examples include the ‘pins and needles’ tingling sensations that many people experience regularly). Parasthaesia includes any non-permanent skin sensation including tickling, pricking, tingling, numbness, and/or burning. ES sufferers will focus on any unusual body mark on their skin as ‘evidence’ that they have a parasitic infection. It is not uncommon for obsessive and/or compulsive checking of the body to occur. The prevalence of ES is unknown although Dr. J. Koo and Dr. C. Gambla reported in the journal Dermatologic Clinic that they see around 20 new cases per year in the large US referral clinic.
In some psychological circles, ES has been used synonymously with Wittmaack-Ekbom syndrome that is more associated with ‘restless leg syndrome’ (RLS; something that I myself have suffered from due to a chronic spinal condition that I have). When I get my bouts of RLS, it really does feel as though I have tiny insects moving about inside my right leg. The difference between ES and RLS is that RLS is a real physical condition that has bona fide physical basis whereas the basis for ES is an imaginary delusion. Clinical and medical research has shown that ES is associated with a number of comorbid conditions including affective psychosis, paranoid schizophrenia, organic brain disease, neurosis, and anankastic/paranoid personality disorder. It has also been reported in some people undergoing alcohol withdrawal, cocaine misuse, cerebrovascular disease, senile dementia, and thalamic brain lesions.
There can also be medical complications for ES sufferers. The fictional example of someone pulling their teeth out is not unknown although the gouging or digging out of the perceived parasites is more common. However, a paper by Dr. M. Nel and colleagues in the Journal of the South African Veterinary Association, most ES sufferers are able to function normally in all other aspects of their lives, in spite of their fixed parasitic delusions. They also noted that:
“The typical history often describes numerous attempts at eradicating the infestation. These could include taking medication, applying topical treatments, using pesticides, making use of exterminators, discarding clothing and possessions and even relocating…In a study of 94 patients (Ohtaki, 1991), most patients complained of itching and/or a tickling sensation. In order to rid themselves of the so-called parasites, patients often scratch, pick and wash frequently or use caustic agents on their skin, almost invariably leading to traumatic skin lesions”.
According to one meta-analytic study of 1,223 ES cases (published by Dr. W. Trabart in the journal Psychopathology), the occurrence of ES as a shared psychotic disorder is an uncommon phenomenon. He reported only about 5-15% of such cases were found. It was also reported that ES was more common amongst females (two-thirds female, one-third male), and is more prevalent in those over the age of 40 years. The symptoms had lasted three to four-and-a-half years. ES can be classified into three sub-types (primary; secondary-functional; and secondary-organic) based on the presenting symptoms:
- Primary ES refers to individuals that have the delusional parasitic infestation but no other comorbid conditions (i.e., other mental functioning is normal). Those where ES occurs by suggestion from another individual (e.g., the folie a deux case mentioned above) would be included in this ES sub-type. (It’s also worth noting that at least three studies have reported either the folie à deux or folie à trois among family members or loved ones including papers in the British Journal of Psychiatry and Dermatologica). Treatment is usually pharmacotherapy-based and utilizes drugs that are used in the treatment of other delusional-based syndromes (e.g., atypical antipsychotic drugs such as risperidone and olanzapine.
- Secondary-functional ES refers to individuals that have the delusional parasitic infestation and are associated with another psychiatric condition (e.g., clinical depression, schizophrenia).
- Secondary-organic ES refers to individuals that have the delusional parasitic infestation that is caused by another medical illness (e.g., cancer, diabetes, tubercolosis, hyperthyroidism, vitamin deficiency, cerebrovascular disease, neurological disorders). Other conditions can also facilitate ES including drug abuse (including stimulant psychosis), various allergies, and the menopause). Treating the primary disorder will often lead to a reduction or elimination of the ES symptoms.
The most recent review of the literature I came across was by Dr. Andrea Boggild and colleagues, and published in a 2010 issue of the International Journal of Infectious Diseases, they concluded that:
“In summary, [delusional parasitosis] is one of the more challenging entities that infectious diseases specialists will be enlisted to help treat. Unfortunately, optimal therapeutic regimens leading to sustained remission are lacking, and assurances on the part of the clinician do little to ameliorate patient suffering”.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Berrios GE (1985). Delusional parasitosis and physical disease. Comprehensive Psychiatry 26, 395-403.
Boggild, A.K., Nicks, B.A., Yen, L., Voorhis, W.V., McMullen, R., Buckner, F.S., & Liles, W.C. (2010). Delusional parasitosis: six-year experience with 23 consecutive cases at an academic medical center. International Journal of Infectious Diseases, 14, e317–e321.
Bourgeois, M.L., Duhamel, P. & Verdoux, H. (1992). Delusional parasitosis: Folie à deux and attempted murder of a family doctor. British Journal of Psychiatry, 161, 709-711.
Frances, A. & Munro, A. (1989). Treating a woman who believes she has bugs under her skin. Hospital and Community Psychiatry, 40, 1113–1114.
Freinhar, Jack P (1984). Delusions of parasitosis. Psychosomatics, 25, 47-53.
Gieler, U. & Knoll, M. (1990). Delusional parasitosis as ‘folie à trois’. Dermatologica, 181, 122-125.
Goddard J (1995). Analysis of 11 cases of delusions of parasitosis reported to the Mississippi Department of Health. Southern Medical Journal 88, 837-839.
Gould, W.M. & Gragg, T.M. (1976). Delusions of parasitosis. Archives of Dermatology 112, 1745–1748.
Grace, K.J. (1987). Delusory cleptoparasitosis: Delusions of arthropod infestation in the home. Pan-Pacific Entomologist, 63, 1-4.
Koblenzer, C.S. (1993). The clinical presentation, diagnosis and treatment of delusions of parasitosi: A dermatologic perspective. Bulletin of the Society of Vector Ecologists 18, 6-10.
Koo, J. & Gambla, C (1996). Delusions of parasitosis and other forms of monosymptomatic hypochondriacal psychosis. General discussion and case illustrations. Dermatologic Clinic, 14, 429-438.
Morris, M. (1991). Delusional manifestation. British Journal of Psychiatry, 159, 83-87.
Hinkle, N.C. (2000). Delusory parasitosis. American Entomologist 46, 17-25.
Ohtaki, N. (1991). Ninety four cases with delusions of parasitosis. Japanese Journal of Dermatology, 101, 439-446.
Rasmussen, J.E. & Voorhees, J.J. (1990). Psychosomatic dermatology. Archives of Dermatology, 126, 90-93.
Nel, M., Schoeman, J.P. & Lobetti, R.G. (2001). Delusions of parasitosis in clients presenting pets for veterinary care. Journal of the South African Veterinary Association, 72, 167-169.
Trabert, W. (1995). 100 years of delusional parasitosis. Meta-analysis of 1,223 case reports. Psychopathology, 28, 238-46
Webb, J.P. (1993). Case histories of individuals with delusions of parasitosis in southern California and a proposed protocol for initiating effective medical assistance. Bulletin of the Society of Vector Ecologists 18, 16-24.
Tat’s life: A brief look at extreme tattooing on film
Anyone who knows me will tell you that I don’t mind a bit of ‘pop psychology’ every now and again (and have even wrote articles defending it – see ‘further reading’ section below). I’m also someone who believes that art not only imitates life, but life can sometimes imitate art. This has led me to write academic articles on films (such as The Gambler) to see what extent the film represents the reality of psychological conditions. I’m also someone who uses film clips as teaching aids as sometimes film or a two-minute film clip says more than any academic paper about a particular psychological concept. (For instance, I think the film 12 Angry Men probably says more about the psychology of minority influence than any paper I’ve read on the topic). All this preamble is by way of saying there’s not a lot of academic research in this blog, and is one of the few times I will just write about whatever is on my mind.
Anyway, I was travelling back from a work trip to South Korea recently and caught up with a lot of films that I had been meaning to watch for some time. I watched four particular films on one plane flight – Eastern Promises, (released in 2007), Tattoo (2002), Red Dragon (2002), and The Girl With The Dragon Tattoo (2011) – where (quite by coincidence) tattoos were a fundamental part of three of the four story lines (perhaps somewhat ironically, the plot of The Girl With The Dragon Tattoo has little to do with tattoos). Soon after after I got back from my South East Asia trip, Channel 4 then screened a television documentary called My Tattoo Addiction. This got me thinking about how tattoos have become part of the mainstream and how for some people it borders on the obsessive. In a previous blog I briefly looked at the sexually paraphilic side of tattoos when I wrote about stigmatophilia (i.e., individuals being sexually aroused by scarring but now seems to include those who are sexually aroused by tattoos and piercings). However, today’s blog takes a brief look at the non-sexually obsessive elements of tattoos.
In the film Eastern Promises (directed by one of my favourite directors David Cronenberg), the actor Viggo Mortensen plays the character Nikolai Luzhin who is the driver of a man who used to be of high standing in the Russian mafia. I’m not going to reveal any of the story line but all the tattoos in the film tell the life stories of incarcerated Russian criminals who typically have dozens of tattoos all over their bodies. Here, the constant adding of tattoos is part of the subculture and has a purpose that has nothing to do with style or fashion, and is more to do with life history and psychological identity.
To acclimatize to his role, Mortensen researched and studied Russian gangsters (called the ‘vory’) and their tattoos. More specifically, he worked with Dr Gilly McKenzie (a Russian Mafia/organized crime specialist who worked for the United Nations) and watched relevant documentaries like The Mark of Cain that contains an in-depth examination of Russian criminal tattoos. For instance, in researching this blog I have since learned that among Russian prisoners (i) an upwards-facing spider tattoo refers to an active criminal, (ii) a pair of eyes on the underside of the abdomen refers to the person being homosexual, and (iii) a skull inside a square (as a finger ring) refers to a robbery conviction. Mortensen’s tattoos were incredibly realistic (so much so that when making the film, he had dinner in a Russian restaurant in London and the other diners stopped talking out of fear!). Mortensen also admitted that:
“I talked to [real Russian gangsters] about what [the tattoos] meant and where they were on the body, what that said about where they’d been, what their specialties were, what their ethnic and geographical affiliations were. Basically their history, their calling card, is their body.”
Given the title of the film, it’s not surprising that the film Tattoo (directed by German film director Robert Schwentke) features tattoos as fundamental to the story plot. The main underlying story involves a serial killer who is obsessively murdering people for their tattoos (i.e., the body tattoos are viewed as a work of art by thekiller). The subject of killing people for their tattoos has been covered in other stories (most notably by Roald Dahl in his short story Skin) but the film is very good and unlike Eastern Promises where the seemingly obsessive motivation for the tattoos is a statement about life history and belonging to their cultural group (the vory), in this film the people who have all over body tattoos are a walking piece of art and the obsession is with the unseen protagonist.
I ought to mention there is another (1981) film called Tattoo (directed by Bob Brooks) that is about tattoo obsession. In this earlier film, Bruce Dern plays the character Karl Kinsky, a mentally unstable tattoo artist who makes his living by creating temporary tattoos for models. Kinsky becomes obsessed with a model (Maddy), kidnaps her, and forces her to wear ‘his mark’ (i.e., a full body tattoo). He keeps her captive as he creates his masterpiece on her body. The strapline on all the film posters says it all: “Every great love leaves its mark”.
In the film Red Dragon, (based on Thomas Harris’ novel of the same name), one of the film’s main characters (Francis Dolarhyde) has a huge tattoo of (surprise, surprise) a red dragon on his back because of his extreme obsession with William Blake’s painting The Great Red Dragon and what he feel it represents. The tattoo covered all of Dolarhyde’s back, and extended onto his upper arms and down onto his buttocks and legs (although this doesn’t win the prize for the most tattooed man in a film – that surely must be ‘Carl’ played by Rod Steiger in the 1969 film The Illustrated Man).
What I find fascinating about all these films is the different ways that psychological obsessions can manifest themselves, and how the stories involving tattoos are totally believable because tattoos have become so much part of Westernized culture over the last decade. Not only that but tattoos have become ‘normalized’ and call into question academic research into excessive tattooing. For instance, I recently read a 2002 case report by Dr. Harpreet Duggal on repetitive tattooing as an obsessive-compulsive disorder that talked about excessive tattoos being linked to those with an anti-social personality disorder and being a “self-mutilatory behaviour”. Their report (which was only written a decade ago):
“Tattooing has been viewed as an act of self-mutilation (Raspa & Cusack, 1990), the latter being a characteristic of borderline personality disorder. The noteworthy aspect of this case is that tattooing initially represented an act of self-mutilation in consonance with the underlying personality disorder. However, later it became repetitive and had a ‘compulsive’ quality to it, though not a true compulsion by definition. There are rare reports of self-mutilation taking on a compulsive pattern but this mostly occurs with cutting and burning acts”.
This leaves me wondering how heavily tattooed celebrities like David Beckham, Johnny Depp, Robbie Williams, and Angelina Jolie would feel if they read how their behaviour might be pathologized by psychologists and psychiatrists alike?
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Duggal, H.S. & Fisher, B. (2002). Repetitive tattooing in borderline personality and obsessive- compulsive disorder. Indian Journal of Psychiatry, 44, 190–192.
Griffiths, M.D. (1995). ‘Pop’ psychology. The Psychologist: Bulletin of the British Psychological Society, 8, 455-457.
Griffiths, M.D. (1995). Pop psychology and “aca-media”: A reply to Mitchell. The Psychologist: Bulletin of the British Psychological Society, 8, 537-538.
Griffiths, M.D. (1996). Media literature as a teaching aid for psychology: Some comments. Psychology Teaching Review, 5(2), 90.
Griffiths, M. (2004). An empirical analysis of the film ‘The Gambler’. International Journal of Mental Health and Addiction, 1(2), 39-43.
Raspa, R.F. & Cusack, J. (1990) Psychiatric implications of tattoos. American Family Physician, 41,1481-1486.
Blown away: A brief overview of balloon fetishism
Balloon fetishes are (unsurprisingly) sexual fetishes that feature balloons as the source of sexual arousal and pleasure. Such individuals are known as ‘looners’. David Kerekes (editor of Headpress – The Journal of Sex, Death and Religion) wrote that some balloon fetishists “revel in the popping of balloons and [others] may become anxious and tearful at the very thought of popping balloons”. In her book Deviant Desires, Katharine Gates also notes that other looners enjoy particular aspects of balloons such as blowing them up and/or interacting with them (e.g., rubbing up against balloons, sitting and/or lying on balloons, etc.). A quick look at a few balloon fetish websites also indicates that some looners like watching people inflate them until they burst whereas others like gigantic balloons that they can stick their head inside them (for instance, check out the pictures here which also claim that the smell or the colour of the balloon may be an important part of the fetish).
There has been very little empirical research carried out on looners and much of what is known is based on anecdotes and hearsay. Anecdotal case studies suggest that the etiology of the fetish varies from one person to the next although some claim that the behaviour can be explained by sexual imprinting where specific sexual preferences may be acquired through exposure to particular stimuli during a specific period early in life. Some looners recall that in childhood they remember being sexually aroused when they saw balloons being popped by the opposite sex (or people they had a crush on). It has also been alleged that – somewhat paradoxically – looners may have phonophobia (i.e., a fear of loud sounds) as a result of being in the vicinity of balloons popping loudly. As Dr. Ilana Simons claims in a Psychology Today article, there is an unexplained link between fetishes and phobias:
“There is a deep connection between phobias, fetishes, and Obsessive-Compulsive Disorder. In each, someone has an emotion that threatens to overwhelm her… A person with a fetish handles the monster of desire by focusing not on whole people but on parts – just a shoe, or the butt, or the slit in skirts. Focus on one thing organizes or restrains multiple feelings. A person with a phobia is similarly able to contain anxiety by condensing emotion to one target”.
In an online essay (So hot and ready to pop: The world of looners), balloon fetishists comprise poppers (where popping the balloon is essential to the fetish) and non-poppers (who avoid the bursting of balloons in all instances). Katherine McIntyre recently published a paper on balloon fetishes (Looners: Inside the world of balloon fetishes) and interviewed a number of looners. One of her interviewees claimed that poppers are generally more dominant and non-poppers more submissive. However, sex therapist Paul Abramson claimed the distinction was trivial and “like trying to distinguish Miller from Bud drinkers”. McIntyre also noted that:
“The balloon fetish community extends beyond porn. Looners share stories and ask questions about their fetish on Facebook, Twitter and other Internet sites. About 1,200 people are regular members of Balloon Buddies, a popular listserv in the looner community where otherwise uncomfortable and often ashamed balloon people gather and discuss their preoccupation. Balloon Buddies was started as a pen pal group in the 1970s by a man from Maine nicknamed Buster Bill. Several thousand people have circulated through over the years”.
Even among looners who don’t have a balloon phobia, it has been claimed that may have no desire to burst the balloon because they have an anthropomorphized emotional attachment to the balloon (i.e., they attribute human characteristics to the balloon). The article also claims that balloon fetish is indirectly related to latex fetishes. Just like latex, balloons are “tactile and supple and imitate the consistency of human skin”. However, balloons have extra properties such as the ability to expand and is said to be akin “the swelling of primary and secondary sexual organs during arousal”. A Wikipedia entry on looners also claims that:
“One hallmark of the distinction between poppers and non-poppers may be in seeing balloons’ bursting either as a metaphor for orgasm, or as a metaphor for death…for fetishists the adrenaline rush associated with the ‘danger’ that a balloon will pop produces a sexual response. This helps to explain why even non-poppers who have an intense phobia of balloons popping in non-sexual contexts may be aroused by the possibility within safe sexual contexts. It may even suggest that balloon fetish, for poppers and non-poppers alike, is part of the BDSM [Bondage, Dominance, Submission, Masochism] spectrum of fetishes in which a controlled amount of danger is used to elicit a pleasurable fight or flight in participants”.
In an article for The Wave Magazine, entitled “Fetish Confessions”, Sandy Brundage interviewed self-confessed looner ‘Mike D’ about his balloon fetish. Brundage simply wanted to know why looners are so sexually aroused by balloons. Mike D – who now runs the balloon fetish video site Mellyloon that has sent out over 1,000 balloon fetish films to the Middle East, Asia, South and North America – said:
”I’m not sure I have the answer to that. There’s always something that goes back to your childhood. Like your babysitter blew up a balloon or your mother popped your balloon. Then along comes puberty and these things that made such an impression on you as a child turn into something erotic….I’m still phobic [about balloons]. That’s where my whole fetish derived from, that fear”.
McIntyre interviewed another male looner (Shaun) who was particularly aroused by balloons because of their smell. He said:
“The smell of a room that has a lot of balloons, especially after they have oxidized over a period of a couple days, is nearly indescribable. Each brand possesses a smell as distinct to looners as perfume. The odor is subtly sweet with a hint of rubber. One sniff can identify a Rifco brand product because its latex smells slightly of chocolate chip cookies. The aroma adds to the experience, as does the feel and sound of balloons. The sensation of swimming through hundreds of balloons in my bedroom was overwhelming and amazing”.
McIntyre also noted that some looners care more about the balloon’s size, colour and brand. Some prefer solid colored balloons and others prefer transparent balloons. One looner said that size was crucial (“the bigger the better”). This particular looner claimed he could orgasm simply by blowing up a balloon until it popped.
McIntyre also interviewed Lynda, a 55-year-old teacher from Los Angeles who said that balloons were “more sensual than sexual” for her. She and her partner own three helium tanks and they sometimes fill their bedroom, living room or shower with balloons. Lynda says she traps herself in a cage she built with balloons, turns on a large fan, and allows the balloons to move around her. This she says stimulates “her senses to invigorating heights” and equates the feeling to a junkie’s high (“so intense, so wild and awesome”), and “collapses in ecstasy afterward like one does after incredible sex”. Lynda says her partner accepts her balloon fetish because “it’s not immoral, not fattening, it’s relatively cheap and brings a smile to her face”.
McIntyre also claimed in her article that most looners grew up ashamed with the belief that no-one else in the world had their sexual fetish. It was only when they found other like-minded people online that they realized they were “not alone”. This helps eliminate the looner’s feelings of isolation. This then becomes easier to tell potential partners about their fetish and helps looners to keep their behaviour under control.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Brundage, S. (2002). Fetish Confessions: Telling loved ones about your fetish is as easy as solving fractured quadratic equations. The Wave Magazine, July 31. Located at: http://web.archive.org/web/20071110095616/http://thewavemagazine.com/pagegen.php?pagename=article&articleid=22026
Gates, K. (2000). Deviant Desires: Incredibly Strange Sex. New York: RE/Search Publications.
Kerekes, D. (2010). Headpress: The Journal of Sex, Death and Religion, 21, 142.
Malfouka (undated). So hot and ready to pop: The world of looners. Maximum Awesome. Located at: http://www.maximumawesome.com/pervfriday/looners.htm
McIntyre, K.E. (2011). Looners: Inside the world of balloon fetishism. Berkeley Graduate School of Journalism, UC Berkeley, 27 April. Located at: http://escholarship.org/uc/item/40c3h6kk
Simons, I. (2009). On fetishes and clean pencil tips. Psychology Today, March 8. Located at: http://www.psychologytoday.com/blog/the-literary-mind/200903/fetishes-and-clean-pencil-tips
Wikipedia (2012). Balloon fetish. Located at: http://en.wikipedia.org/wiki/Balloon_fetish
It’s in the stars: A brief psychological overview of Celebrity Worship Syndrome
Celebrity worship syndrome has been described as an obsessive-addictive disorder where an individual becomes overly involved and interested (i.e., completely obsessed) with the details of the personal life of a celebrity. Any person who is “in the public eye” can be the object of a person’s obsession (e.g., authors, politicians, journalists), but research and criminal prosecutions suggest they are more likely to be someone from the world of television, film and/or pop music.
Among academic researchers, the term “celebrity worship” (CW) is a term that was first coined by Dr. Lynn McCutcheon (DeVry University, US) and her research colleagues in the early 2000s. However, it is commonly believed that the first use of the term ‘Celebrity Worship Syndrome’ (CWS) was in a Daily Mail article by the journalist James Chapman (in an article entitled “Do you worship the celebs?”) who was reporting on a study published by Dr. John Maltby and colleagues (University of Leicester, UK) in the Journal of Nervous and Mental Disease entitled “A Clinical Interpretation of Attitudes and Behaviors Associated with Celebrity Worship”. CWS was actually an acronym for the “Celebrity Worship Scale” used in the study. Chapman also called the behaviour exhibited by such people as “Mad Icon Disease” (obviously a play on ‘Mad Cow Disease’ that was high on the news agenda in the UK at the time).
Despite the (presumably) accidental misnomer, the condition may in fact be indeed indicative of a syndrome (i.e., a cluster of abnormal or unusual symptoms indicating the presence of an unwanted condition). US research carried out on a small sample in the early 2000s by Dr. Lynn McCutcheon’s team using the ‘Celebrity Attitudes Scale’ suggested a single ‘celebrity worship’ dimension. However, subsequent research on much bigger samples by Dr. Maltby and his team identified three independent dimensions of celebrity worship. These were on a continuum and named (i) entertainment-social, (ii) intense-personal, and (iii) borderline pathological.
- The entertainment-social dimension relates to attitudes where individuals are attracted to a celebrity because of their perceived ability to entertain and to become a social focus of conversation with likeminded others.
- The intense-personal dimension relates to individuals that have intensive and compulsive feelings about a celebrity.
- The borderline-pathological dimension relates to individuals who display uncontrollable behaviours and fantasies relating to a celebrity.
Maltby and colleagues have now published numerous papers on celebrity worship and have found that there is a correlation between the pathological aspects of CWS and poor mental health in UK participants (i.e., high anxiety, more depression, high stress levels, increased illness, poorer body image). Most of these studies have been carried out on adults. However, studies relating to body image have also included adolescents, and have found that among teenage females (aged 14 to 16 years) there is a relationship between intense-personal celebrity worship and body image (i.e., those teenage girls who identify with celebrities have much poorer body image compared to other groups studied). Maltby’s team’s research also seems to indicate that the most celebrity-obsessed individuals often suffer high levels of dissociation and fantasy-proneness. Dr. Maltby summarized his team’s research in an interview to the BBC. He said:
‘Data from 3,000 people showed only around 1% demonstrate obsessional tendencies. Around 10% (who tend to be neurotic, tense, emotional and moody) displayed intense interest in celebrities. Around 14% said they would make a special effort to read about their favourite celebrity and to socialize with people who shared their interest. The other 75% of the population do not take any interest in celebrities’ lives. Generally, the vast majority of people will identify a favourite celebrity, but don’t say they read about them or think about them all the time. Like most things, its fine as long as it doesn’t take over your life”.
The same article sought other scientific views from a biological angle. They reported that.
“Evolutionary biologists say it is natural for humans to look up to individuals who receive attention because they have succeeded in a society. In prehistoric times, this would have meant respecting good hunters and elders. But as hunting is not now an essential skill and longevity is more widely achievable, these qualities are no longer revered. Instead, we look to celebrities, whose fame and fortune we want to emulate. Evolutionary anthropologist Francesco Gill-White from the University of Pennsylvania in Philadelphia told New Scientist: ‘It makes sense for you to rank individuals according to how successful they are at the behaviours you are trying to copy, because whoever is getting more of what everybody wants is probably using above-average methods’. But Dr Robin Dunbar, an evolutionary biologist at the University of Liverpool, said following celebrities did not necessarily mean they were seen as role models. ’We’re fascinated even when we don’t go out of our way to copy them’. He said people watched how celebrities behaved because they received a great deal of wealth from society and people wanted to ensure it was invested properly”.
Maltby and colleague’s reasearch also shows that CW is not just the remit of adolescent females but affects over a quarter of the people they surveyed (across the three levels mentioned earlier). Their paper in the Journal of Nervous and Mental Disease, reported that CW brought both positive and negative consequences. People who worshipped celebrities for entertainment and social reasons were more optimistic, outgoing, and happy. Those who worshipped celebrities for personal reasons or were more obsessive were more depressed, more anxious, more solitary, more impulsive, more anti-social and more troublesome. So where do you fit into this in terms of celebrity worship? I’ll leave you with some statements so you can assess your own level of celerity worship (I answered ‘no’ to all nine statements)..
- Say yes to the following and you may have low-level CWS:
- My friends and I like to discuss what my favourite celebrity has done.
- I enjoy watching my favourite celebrity.
- Learning the life story of my favourite celebrity is a lot of fun.
- Agree with these more intense feelings and you may have a moderate case of CWS:
- I consider my favourite celebrity to be my soul mate.
- I have a special bond with my celebrity.
- I have frequent thoughts about my celebrity, even when I don’t want to.
- Agree with these and you may be obsessed, borderline pathological and suffering seriously from CWS:
- If someone gave me several thousand pounds to do with as I please, I would consider spending it on a personal possession, like a napkin or paper plate, once used by my favourite celebrity.
- If I were lucky enough to meet my favourite celebrity, and they asked me to do something illegal as a favour I would probably do it.
- I would be very upset if my favourite celebrity got married.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
BBC News (2003). Worshipping celebrities ‘brings success. August 13. Located at: http://news.bbc.co.uk/1/hi/health/3147343.stm
Chapman, J. (2003). Do you worship the celebs? Located at: http://www.dailymail.co.uk/tvshowbiz/article-176598/Do-worship-celebs.html
McCutcheon, L.E., Lange, R., & Houran, J. (2002). Conceptualization and measurement of celebrity worship. British Journal of Psychology, 93, 67-87.
Maltby, J., Houran, M.A., & McCutcheon, L.E. (2003). A Clinical Interpretation of Attitudes and Behaviors Associated with Celebrity Worship. Journal of Nervous and Mental Disease, 191, 25-29.
Maltby, J., Houran, J., Ashe, D., & McCutcheon, L.E. (2001). The self-reported psychological well-being of celebrity worshippers. North American Journal of Psychology, 3, 441-452.
Maltby, J., Day, L., McCutcheon, L.E., Gillett, R., Houran, J., & Ashe, D. (2004). Celebrity Worship using an adaptational-continuum model of personality and coping. British Journal of Psychology. 95, 411-428.
Maltby, J., Giles, D., Barber, L. & McCutcheon, L.E. (2005). Intense-personal Celebrity Worship and Body Image: Evidence of a link among female adolescents. British Journal of Health Psychology, 10, 17-32.
Maltby, J., Day, L., McCutcheon, L.E,. Gilett, R., Houran, J. & Ashe, D.D. (2004), ‘Personality and Coping: A Context for Examining Celebrity Worship and Mental Health. British Journal of Psychology, 95, 411-428.
Maltby, J., Day, L., McCutcheon, L.E., Houran, J. & Ashe, D. (2006). Extreme celebrity worship, fantasy proneness and dissociation: Developing the measurement and understanding of celebrity worship within a clinical personality context. Personality and Individual Differences, 40, 273-283.
Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Towards a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12, 1-8.
Wikipedia (2012). Celebrity Worship Syndrome. Located at: http://en.wikipedia.org/wiki/Celebrity_Worship_Syndrome
Heavy petting: A brief overview of animal hoarding
Last week I was interviewed on BBC radio about Channel 4′s new show ‘The Hoarder Next Door’. In previous blogs, I have briefly examined pathological hoarding and one particular type of hoarding behaviour (i.e., pathological book hoarding). Another very specific type of hoarding is animal hoarding (typically defined as having a higher number of pets than is normal to have and failing to look after them properly). In a 2006 issue of Veterinary Medicine, Dr Gary Patronek (Tufts University, US) defined animal hoarding as: “Pathological human behaviour that involves a compulsive need to obtain and control animals, coupled with a failure to recognize their suffering”. According to a recent literature review led by Dr Albert Pertusa (Institute of Psychiatry, London), this sub-type of hoarding has been defined as the accumulation of a large number of animals along with a:
- Failure to provide minimal standards of nutrition, sanitation, and veterinary care.
- Failure to act on the deteriorating condition of the animals (including disease, starvation or death) and the environment (severe overcrowding, extremely unsanitary conditions)
- Lack of awareness of the negative effects of the collection on their own health and wellbeing and on that of other family members.
Animal hoarders often live in severe domestic squalor and live in more unsanitary conditions than other types of hoarder (although some other types of disorder such as Diogenes Syndrome – also known as ‘senile squalor syndrome’ – is characterized by extreme self-neglect, apathy, domestic squalor, social withdrawal, compulsive hoarding of rubbish, and lack of shame). It is common for the houses of animal hoarders to be filled with animal faecal waste, and it is not unusual to find the decomposing remains of dead animals. The animals are often left to reproduce at will as animal hoarders do not typically get their pets spayed or neutered. Sick animals are typically left to die and rot. A 2009 study by Dr Gary Patronek and Jane Nathanson examined the living areas of 49 animal hoarders. They reported that four out of five living areas were “heavily littered with trash and garbage” (78%), and that in just under a half there was “profuse urine or feces in the living spaces” (45%).
One very key difference between animal and non-animal hoarders is that animal hoarding may involve animal cruelty. Dr Frank Ascione (Utah State University) defines animal cruelty as a “socially unacceptable behavior that intentionally causes unnecessary pain, suffering, or distress to and/or death of an animal”. Ascione believes that animal neglect falls within this definition and that therefore animal hoarders are guilty of animal cruelty. However, some researchers claim that the animal cruelty is not deliberate as the compulsive hoarding is underpinned by some kind of mental disorder.
Many animal hoarders are known to hoard other items and objects, and therefore some experts in the area (such as Patronek and Nathanson) suggest that animal hoarding is a special manifestation of compulsive hoarding. There is also some research that suggests that animal hoarding follows more ‘conventional’ hoarding. However, animal hoarders share many of the same characteristics as those with Diogenes Syndrome. It has also been suggested that animal hoarders had very controlling parents, come from backgrounds that were chaotic and/or deprived in childhood (and sometimes described as scary and frightening), have psychological issues and problems surrounding emotional attachments, and often attribute human characteristics to the animals they own. Another seemingly common theme is that of physical and/or psychological loss. For animal hoarders, losing a possession is for them like losing a close friend or family member. It has also been claimed that some animal hoarders are often incapable of looking after and caring for themselves (let alone animals – particularly if there are so many of them).
Colin Berry and colleagues, writing in an overview on animal hoarding for the journal Animal Law cited a 2002 review by Arnold Arluke and reported:
“Arnold Arluke analyzed one hundred articles about animal hoarding. Arluke suggests that, rather than presenting a realistic picture of animal hoarding that captures the complexity of the issue, the media presents animal hoarding in a stream of different emotional themes. While drawing the reader’s attention, these themes are more likely to elicit revulsion, sympathy, or humor from the reader rather than understanding of the hoarding issues themselves. Arluke concludes that these emotional themes ‘present an inconsistent picture of animal hoarding that can confuse readers about the nature and significance of this behavior.’ Portraying hoarders’ stories in this light can cause the public to be sympathetic and even supportive of the hoarder and her actions. Some hoarders even receive donations or offers of more animals”.
In the same paper, Berry and colleagues also noted that in terms of demographics, empirical studies have found that animal hoarders are typically middle-aged or older females who are often disabled, retired, or unemployed, living alone in homes without working appliances. The animals that are most likely to be hoarded are cats (the highest number they came across being owned was 400) and dogs (the highest number owned being 218). They also noted that numerous psychological models have been proposed to explain animal hoarding, including focal delusion, addiction, obsessive-compulsive disorder (OCD), zoophilia, and dementia. Although there is no consensus, the conceptualizing of animal hoarding as a form of OCD appears to be the most popular explanation (although this does not appear to explain all cases). According to Karen Cassiday, no-one knows what the prevalence of animal hoarders is within any population although press reports over the last decade have quintupled. Whatever the prevalence, animal hoarding is an area that needs further investigation.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Arluke, A. et al. (2002). Press reports of animal hoarding. Society and Animals, 113, 130-32.
Ascione, F. (1993). Children who are cruel to animals: A review of research and implications for developmental psychopathology. Anthrozoos: A Multidisciplinary Journal of The Interactions of People & Animals, 6, 226-247.
Berry, C., Patronek, G. & Lockwood, R. (2005). Long-term outcomes in animal hoarding cases. Animal Law, 11, 167-194.
Cassiday, K.L. (undated). Animal hoarding: An overlooked and misunderstood problem. Located at: http://www.ocdchicago.org/images/uploads/pdf/Cassiday_-_Animal_Hoarding_-_An_Overlooked_and_Misunderstood_Problem.pdf
Patronek, G. J., & Nathanson, J. N. (2009). A theoretical perspective to inform assessment and treatment strategies for animal hoarders. Clinical Psychology Review, 29, 274−281.
Pertusa, A., Frost, R.O., Fullana, M.A., Samuels, J., Steketee, G., Tolin, D., Saxena, S., Leckman, J.F., Mataix-Cols, D. (2010). Refining the diagnostic boundaries of compulsive hoarding: A critical review. Clinical Psychology Review, 30, 371-386.
Reinisch, A.I. (2008). Understanding the human aspects of animal hoarding. Canadian Veterinary Journal, 49, 1211-1214.
Well and truly booked: A beginner’s guide to bibliomania
“Some people think that collecting old books is a kind of mild insanity. The collector, on his side, smiles upon the ignorant who cannot understand the enjoyment of collecting. The philosopher says: Ne quid nimis, go not too far. But all of the adages this one is the most difficult to follow. The bibliophile is the master of his books, the bibliomaniac their slave. With development of bibliomania, the friendly, warming flame of a hobby become devastating, ravaging wildfire, a tempest of loosened and vehement passions. We are then in the presence of a pathological, irresistible mental compulsion, which has produced more than one crime interesting enough to be remembered”
What amazes me about this opening quote is that it was written almost 70 years ago. It comes from an article by Dr. Martin Sander published in the Journal of Criminal Law and Criminology (1943). So what’s the evidence for the existence of “bibliomania”? Does it really exist? In a nutshell, yes.
Bibliomania has been reported to be a symptom of some obsessive-compulsive disorders particularly those associated with the collecting and hoarding of books. For a small minority, bibliomania can result in the breakdown of personal relationships and/or the damaging of the person’s health. It is believed that the condition had no generally accepted name until 1866. Dr. John Ferriar – a British physician from Manchester – had a poem published simply entitled “Bibliomania”.
In his 2001 book The Anatomy of Bibliomania, Holbrook Jackson noted that English bibliographer Thomas Dibdin (1776-1847) wrote about bibliomania. Dibdin described the condition as a fatal affliction and referred to it as “the Book disease” that has “almost uniformly confined its attacks to the male sex, and among these, to the people in the higher and middling classes of society, while the artificer, labourer, and peasant have escaped wholly uninjured”.
In recent history, arguably the most well known bibliomaniac was Stephen Blumberg from Iowa (US). The so-called “book bandit” was convicted of stealing $5.3 million worth of books (over 23,600 books). In 1991 during Blumberg’s trial, the forensic psychiatrist Dr. William S. Logan noted that Blumberg had been treated for compulsive behaviour and had suffered schizophrenic delusions ad that these conditions had underpinned his bibliomania. Following a four-and-a-half year prison sentence, Blumberg was released but immediately resumed his book collecting and stealing.
Despite the condition being written about for 150 years, bibliomania is not a psychological disorder recognized by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. Bibliomaniac behaviours include the multiple purchasing of the same book and in more extreme cases the persistent stealing of books. One of the defining features of bibliomania is that the acquisition and collecting of increasing numbers of books have no use to the bibliomaniac, nor little intrinsic value to genuine book collectors. Other book-related conditions include ‘bibliophilia’ (which is simply the love of books but not in a paraphilic sense), ‘bibliokleptomania’ (the stealing of books), ‘bibliophagy’ (the eating of books), and ‘bibliotaphy’ (the burying of books).
Dr Norman Weiner wrote a theoretical paper on bibliomania in a 1966 issue of the Psychoanalytic Quarterly because it had “largely been ignored by psychoanalysts”. He noted that few people enter treatment for bibliomania and speculated that this was because the activity may be ego-syntonic (i.e., a behaviour that is in harmony with and acceptable to the needs and goals of the person’s ego or ideal self-image). He also provided case study evidence that for some people, the act of book collecting as a hobby may cause psychological conflict that for sufferers relieves anxiety.
Writing in a 2006 issue of the International Journal of Psychoanalysis, Dr. Peter Subkowski wrote that the urge to collect is a ubiquitous phenomenon that has anthropological, sociobiological and individual psychodynamic roots (not surprising given that Subkowski is a psychoanalyst). He also claims that collecting occurs far more frequently among men than women. He describes collecting as an activity that can be “addictive, obsessive and messy””. From his psychoanalytical standpoint, Subkowski claimed that the type of collecting and choice of object were important indicators as to the unconscious psychodynamics of a collector and that:
“Collecting ranges across a broad spectrum, from an ego-syntonic integrated mode (i.e. sublimation) to a neurotic defence against pre-oedipal or oedipal traumas and conflicts…Collecting represents a specific form of object relating and way of handling primary loss trauma, which is different from addiction, compulsion, or perversion”.
When researching this article, I came across very little academic research on the topic although there has been a fair amount of research on collectors. For instance, Dr. Russell Belk (1991) writing in the Journal of Social Behavior and Personality describes collectors of mass-produced objects as falling into one of two main types: the taxonomic collector who attempts to own an example of every type of a series of items produced, and the aesthetic collector who simply gathers items because they are pleasing in some way. Belk also describes collecting as “fetishistic” and that collecting items and bringing them together makes them sacred.
In a 1991 issue of the Journal of Social Behavior and Personality, Ruth Formanek’s suggested five common motivations for collecting. These were: extension of the self (e.g., acquiring knowledge, or in controlling one’s collection); social (finding, relating to, and sharing with, like-minded others); preserving history and creating a sense of continuity; financial investment; and finally, an addiction or compulsion. Formanek says that what is common to all motivations to collect is a passion for the particular things collected. Professor Donald Case (University of Kentucky, US) in a 2006 review of collecting in the journal Library Trends says that it is this almost “sexual excitement” that led many early psychologists (including Freud) to see collecting as a manifestation of anal-erotic impulses.
An empirical survey by Formanek of 167 people (a mixture students, university staff members, collectors, art dealers, etc.) was published as a book chapter in the 1994 book Interpreting Objects and Collections (edited by Dr. Susan Pierce). One of the primary objectives of Formanek’s study was to look at the motivation of book collectors. She noted that:
“An important motivation is the feeling of excitement and elation. Referred to but as yet unexplored in the literature, is the collector’s addiction to collecting. The terms ‘obsession’ and ‘compulsion’ are mentioned chiefly in the popular literature, and are not distinguished from addiction”.
Of those who completed the survey, nine of the participants specifically mentioned addiction, obsession and compulsion as one of the reasons for collecting books although only one collector went into any detail. There were many other motivations for book collecting listed including the books being a financial investment, the challenge of the hunt, adding to one’s knowledge, and “collecting as preservation, restoration, history and a sense of continuity”.
Bibliomania probably means different things to different people and for some it is seen in a more positive light whereas others pathologize the behaviour. It doesn’t look as though the condition will appear in the Diagnostic and Statistical Manual of Mental Disorders any time soon, but there certainly appears to be a small body of empirical evidence to suggest that for some people, book collecting can be compulsive.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Belk, R. W. (1991). The ineluctable mysteries of possessions. Journal of Social Behavior and Personality, 6(6), 17-55.
Case, D.O. (2006). Serial collecting as leisure, and coin collecting in particular. Library Trends, 57(4), 729-752.
Formanek, R. (1991). Why they collect: Collectors reveal their motivations. Journal of Social Behavior and Personality, 6(6), 275-286.
Formanek, R. (1994). Why they collect: Collectors reveal their motivations. In S.M. Pearce (Ed.), Interpreting Objects and Collections (pp.327-335). London: Psychology Press.
Jackson, H. (2001). The Anatomy of Bibliomania. Urbana: University of Illinois Press.
MacLeod, K. (2004). Romps with Ransom’s King: Fans, Collectors, Academics, and the M. P. Shiel Archives. English Studies in Canada, 30(1), 117-136.
Roland, C.G. (1970). Bibliomania. Journal of the American Medical Association, 212(1), 133-135.
Sander, M. (1943). Bibliomania. Journal of Criminal Law and Criminology, 34, 155-161.
Subkowski, P. (2006). On the psychodynamics of collecting. International Journal of Psychoanalysis, 87, 383-401.
Weiner, N.D. (1966). On bibliomania. Psychoanalytic Quarterly, 35, 217-232.
Once a pun a time: Can telling bad jokes be compulsive?
Ever since I can remember, I’ve always had an unhealthy interest in punning. Whether it’s the titles of my blogs or everyday conversation, I can’t seem to resist getting in a pun wherever I can. (I also have a whole section on my CV dedicated to my ‘humorous’ articles including ones that feature nothing but puns). For the purposes of being clear as to what I am actually talking about, a pun – according to the Oxford English Dictionary – is a form of word play that suggests two (or in some cases more) meanings, by exploiting multiple meanings of words, or of similar-sounding words. Author and lexicographer Samuel Johnson went as far as to claim punning the lowest form of humour. In his book ‘Jokes and Their Relation to the Unconscious’, Sigmund Freud asserted that puns are “the lowest form of verbal joke, probably because they are the cheapest – can be made with the least trouble…[and] merely form a sub-species of the group which reaches its peak in the play upon words proper”.
There are a number of references to various forms of ‘compulsive punning’ in the psychological literature. One such name is that of “Foerster’s syndrome”. This was coined by the Hungarian-British author and journalist Arthur Koestler (1905-1983) in a description of the compulsive punning first described by the German neurologist Otfrid Foerster (1873-1941). Back in 1929, Dr Foerster was carrying out brain surgery on a fully conscious male patient who had a brain tumour. When Foerster began to manipulate the patient’s tumor, the patient began a manic outburst of telling one pun after another.
In 1929, a psychiatrist Dr. A.A. Brill reported what he believed were the first cases of Witzelsücht (“punning mania”) in the International Journal of Psychoanalysis. The word ‘Witzelsücht’ comes from the German words ‘witzeln’ (to make jokes or wisecracks), and ‘sücht’ (a yearning or addiction). This rare condition is characterized as a set of neurological symptoms resulting in an uncontrollable tendency to tell puns, inappropriate jokes, and/or pointless or irrelevant stories at inappropriate times. The patient nevertheless finds these utterances intensely amusing. Brill described some of the cases he had come across including a 31-year man with a brain tumour who made puns “about anything and everything”.
This observation by Dr. Brill is not unsurprising as the condition is most commonly seen in those people that have damaged the brain’s orbitofrontal cortex (situated in the frontal lobes of the brain) and often caused by brain trauma, stroke, or a tumour. It is this part of the brain that is most involved in the cognitive processing of decision-making. Old aged people are thought to be most prone to Witzelsucht because of the decreasing amount of grey matter. The condition is also listed in Dorland’s Illustrated Medical Dictionary, which defines Witzelsücht as “a mental condition characteristic of frontal lesions and marked by the making of poor jokes and puns…at which the patient himself is intensely amused”.
It has also been observed that those people with hypomanic disorders are also more prone to engage in excessive punning. During hypomanic epidodes, people’s speech is typically louder and more rapid than usual. Furthermore, it may be full of jokes, puns, plays on words, and irrelevancies. Others have noted that hypomanic episodes may comprise unexplained tearfulness alternating with excessive punning and jocularity.
Neurologist Dr. Kenneth Heilman (University of Florida, USA) says he sees several cases of Witzelsücht each year. “One of the most dramatic cases (that I’ve seen) appeared to be attracted to my reflex hammer. After I checked his deep tendon reflexes and put my hammer down, he picked up the hammer and started to check my reflexes, while giggling”. However, Dr. Heilman (as far as I am aware) has not published any of his findings or clinical observations.
A case study published by Dr. Mario Mendez (University of California at Los Angeles, USA) in a 2005 issue of the Journal of Neuropsychiatry and Clinical Neuroscience claimed that Witzselsucht can occur in those with frontotemporal dementia (FTD). Over a period of two years and as dementia set in, a 57-year-old woman became the life and soul of parties, and would laugh, joke, and sing all the time. During medical examinations, she was highly talkative, animated, and disinhibited. Dr. Mendez reported that she was preoccupied with continuous silly laughter, excitement and frequent childish jokes and puns (i.e., Witzelsücht). Magnetic resonance imaging revealed major atrophy in the anterior temporal lobes of the brain. Citing previous (mostly old German) psychiatric literature, Mendez asserted that FTD is a disorder with a range of neuropsychiatric symptoms that can include Witzelsücht. This includes excessive and inappropriate facetiousness, jokes, and pranks. The woman was given a serotonin selective reuptake inhibitor (SSRI) and other psychoactive medications and her Witzelsucht subsided.
Also in 2005, Ying-Chu Chen and colleagues (National Cheng Kung University Medical Center, Taiwan) published a case report of Witzelsücht and hypersexuality after a stroke. The case involved a 56-year-old man who suffered a stroke. The stroke caused a facial palsy and dysphagia (i.e., difficulty in swallowing). Over the next few days, he became gradually more alert. By the fifth day following the stroke, the man became highly talkative. However, he started telling inappropriate jokes and witticisms, and became euphoric, prankish, and opinionated. He was concerned about his resulting functional deficits, but talked about them in a humorous fashion. Simultaneously with the punning, he also developed hypersexual tendencies, and used erotic words when women were nearby. He also harassed young nurses and other female caregivers. He was unable to correct his inappropriate behaviours. His relatives were very surprised at his inappropriate jokes and the hypersexual behaviours, which were different from that before he had the stroke.
Like the case mentioned previously, he was also given an SSRI as part of his treatment. The use of SSRIs produced a moderate reduction of the man’s aberrant behaviours. Although the physical consequences of the stroke improved, the man’s wife reported that his endless jokes were not only inappropriate in terms of context, but were often obscene. His medication was changed and he was given a noradrenaline reuptake inhibitor. Over the following two months, the inappropriate punning and hypersexual behaviors were rarely noticed.
Finally, (for no other reason than to leave you with a smile on your face), I thought I’d leave you with my top 10 favourite puns that have some connection with the topics of my blogs.
- A good pun is its own reword
- A pessimist’s blood type is always b-negative.
- A Freudian slip is when you say one thing but mean your mother.
- A man needs a mistress just to break the monogamy
- Is a book on voyeurism a peeping tome?
- Dancing cheek-to-cheek is really a form of floor play.
- Does the name Pavlov ring a bell?
- A gossip is someone with a great sense of rumour
- When you dream in colour it’s a pigment of your imagination
- When two egotists meet, it’s an I for an I
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Brill, A.A. (1929). Unconscious insight: Some of its manifestations. International Journal of Psychoanalysis, 10, 145-161.
Chen, Y-C., Tseng, C-Y. & Pai, M-C. (2005). Witzelsucht after right putaminal hemorrhage: A case report. Acta Neurol Taiwan, 14, 195-200.
Freud, S. (1960). Jokes and Their Relation to the Unconsciousness. New York: W.W. Norton
Garfield, E. (1987). The crime of pun-ishment. Essays of an Information Scientist, 10, 174-178.
Griffiths, M.D. (1989). It’s not funny: A case study of ‘punning mania’. The Psychologist: Bulletin of the British Psychological Society, 2, 272.
Koestler, A. (1964). The Act of Creation. New York: Penguin Books, New York.
Mendez, M.F. (2005). Moria and Witzelsucht from frontotemporal dementia. Journal of Neuropsychiatry and Clinical Neuroscience, 17, 429-430.
Shammi, P. & Stuss, D.T. (1999). Humour appreciation: a role of the right frontal lobe. Brain, 122, 657-66.
Pica boom? A beginner’s guide to pica
Pica is an eating disorder that has been documented in the psychological literature for hundreds of years and refers to a behaviour in which individuals eat non-nutritive items or substances (such as coal, hair and wood). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines pica as “the persistent eating of nonnutritive substances for a period of at least one month, without an association with an aversion to food”. Therefore, one-off instances of eating non-nutritious items would not constitute pica. Children who occasionally eat items like crayons are rarely diagnosed as having pica. Pica comes from a Latin word for the magpie bird (known for its strange eating behaviours).
The prevalence rates of pica depend on which patient populations have been studied. Prevalence estimates are also skewed by the fact that many people suffering from pica are embarrassed about the behaviour and may not tell anyone and/or seek medial treatment. However, it is well established that pica is more prevalent in children, pregnant women, adults from lower socioeconomic classes, and children with developmental disabilities (such as autism). The incidence of pica is also higher amongst those suffering from family-related stress. Although pica can be a symptom of anaemia (i.e., iron deficiency) and other chemical imbalances, research has shown it is actually more common among those who have normal iron levels.
Prevalence rates of pica have range anywhere between 0.02% and 74% depending on the study and population studied. For instance, studies have reported pica prevalence rates of:
- 0.02% in Danish pregnant women
- 8% in US black pregnant women (pagophagia)
- 9% in Saudi Arabian pregnant women
- 26.5% in Tanzanian pregnant women (geophagia)
- 31% of Californian Mexican pregnant women
- 44% of Mexican pregnant women
- 50% of Nigerian pregnant women
- 74% in Kenyan pregnant women
- 44% in French anaemic patients (vs. 9% matched controls)
- 64% in Turkish anaemic patients (vs. 17% controls)
- 22%-26% in mentally retarded adults
- 34% in sickle cell disease patients
The Danish figure from a study led by Dr Tina Mikkelsen (University of Southern Denmark) is likely to be the most accurate as it was carried out on a sample of 100,000 pregnant Danish women and only 14 of the total sample reported that they had pica. The authors concluded that in privileged populations, pica is more a myth than a reality.
Despite increased research in the area, there has been no definitive explanation as to why some people consume such substances as hair (trichophagia), ice (pagophagia – which I briefly examined in a previous blog), soil/clay (geophagia), wood (xylophagia), stones (lithophagia), glass (hyalophagia), plumbophagia (lead paint chips), or laundry (uncooked) starch (amylophagia). Dr. Ella Lacey (Southern Illinois University) also listed many other non-food substances that pica sufferers may eat that don’t have specific names such as those people who eat paper, balloons, grass, soap, cotton wool, and cigarette butts. Pica is a widespread practice throughout Africa and India. It has also been reported in Australia, Canada, Israel, Iran, Uganda, Jamaica and various European countries. A recent review on pica led by Dr Sera Young (University of California, USA) noted that geophagia is the most common type of pica described in the psychological and medical literature. They also noted that:
- Geophagics frequently eat other non-food stuffs.
- Those who eat more manufactured substances say they use them as a replacement for earth, either because the desired soil is unavailable or socially unacceptable
- Bar the eating of ice, most pica substances are absorptive in the dry state and all easily absorb moisture.
- Pica substances are typically craved with great intensity or ‘‘devouring passion’’
A variety of conditions are known to cause some types of pica including mineral deficiencies, hookworm infection (parasitic infection in the small intestine), coeliac disease (an autoimmune disorder of the small intestine) and Kleine-Levin Syndrome (also known as Sleeping Beauty Syndrome, a neurological disorder characterized by recurring periods of excessive amounts of sleeping and eating). Interestingly, there are culture-specific cases where pica is not related to psychopathological disorders or deficiencies. For instance, black women in Georgia (USA) are known to eat kaolin (white dirt that is actually a clay mineral) – a so-called “culture-bound syndrome” (i.e., a recognizable combination of psychiatric and somatic symptoms that are only within a specific culture or society).
Some pica type disorders may be part of a wider psychiatric condition (such as schizophrenia) and/or may be part of a sexual paraphilia such as the small numbers of people who engage in coprophagia (eating faces) as part of coprophilia and people who engage in urophagia (drinking urine) as part of urophilia. If the primary focus for eating the item or substance was sexual, it would be more likely diagnosed as a sexual paraphila rather than pica. However, many of those with pica claim to love the taste, texture and/or smell of the things they eat. Some studies have suggested an association between pica and addictive behaviors. Others suggest pica is on the obsessive-compulsive disorder (OCD) spectrum of diseases. For instance, a study based on pica case studies by Dr Dan Stein and colleagues (a the University of Stellenbosch, South Africa) came to the conclusion that (based on their case studies), pica may be a symptom of OCD, and that pica may be phenomenologically reminiscent of an impulse control disorder.
For many people, pica is not dangerous but for some there may be complications including (i) parasitic infections (such as geophagics eating soil or copraphagics eating faeces), (ii) internal bodily obstruction (e.g., such as tricophagics getting hair stuck in their intestines), (iii) toxic reactions (e.g., such as autistic children getting lead poisoning from eating painted plaster), (iv) excessive caloric intake (such as that occurring with starch cravings), (v) dental injuries and infections, and (vi) nutritional deficiencies.
As Dr. Lacey concluded: “Pica appears to be a complex behavior that requires deliberate study rather than application of ex post facto single cause theories. Although such theories may motivate any given study of pica, it should be apparent that any single cause model will likely offer only a limited explanation of such diverse practices as have been described in the literature through case reports,’ research studies, and literature ‘reviews of various clinical and applied disciplines”
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
al-Kanhal, M.A., & Bani, I.A. (1995). Food habits during pregnancy among Saudi women. International Journal for Vitamin and Nutrition Research, 65, 206-210.
Ashworth, M., Hirdes, J.P. & Martin, L. (2008). The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Research in Developmental Disabilities, 30, 512-520.
Danford, D.E. & Huber, A.M. (1982). Pica among mentally retarded adults. American Journal of Mental Deficiency, 87, 141-146.
Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemade, U.J. et al (1994). Pica in an urban environment. Journal of Nutrition, 124(6 Suppl): 954S-962S.
Kettaneh, A., Eclache, V., Fain, O., Sontag, C., Uzan, M. Carbillon, Stirnemann, J. & Thomas, M. (2005). Pica and food craving in patients with iron-deficiency anemia: A case-control study in France. American Journal of Medicine, 118, 185-188
Lacey, E. (1990). Broadening the perspective of pica: Literature review. Public Health Reports, 105, 29-35.
López, L.B., Ortega Soler, C.R. & de Portela, M.L. (2004). Pica during pregnancy: A frequently underestimated problem. Archivos latinoamericanos de nutricion, 54, 17-24.
Mikkelson, T.B., Andersen, A.M. & Olsen, S.F. (2006). Pica in pregnancy in a privileged population: myth or reality. Acta Obstetricia et Gynecologica Scandinavica, 85, 1265-1266.
Ngozi, P.O. (2008). Pica practices of pregnant women in Nairobi, Kenya. East African Medical Journal, 85(2), 72-79.
Nyaruhucha, C.N. (2009). Food cravings, aversions and pica among pregnant women in Dar es Salaam, Tanzania. Tanzania Journal of Health Research, 11(1), 29–34.
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Simpson, E., Mull, J.D., Longley, E., & East, J. (2000). Pica during pregnancy in low-income women born in Mexico. Western Journal of Medicine, 173, 20-24.
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Compelling evidence: A beginner’s guide to obsessive- compulsive disorders
Most people’s perceptions of obsession and compulsion – if they have never experienced it personally or have encountered it among family and friends – are probably based on television and film characters who have obsessive-compulsive disorders such as Jack Nicholson playing the novelist Melvin Udall in the film As Good As It Gets, or (my own personal favourite) Tony Shalhoub’s playing Adrian Monk in the detective series Monk. Shalhoub’s portrayal of Monk as a dirt phobic, symmetrically obsessed, ex-policeman who never walks on cracks in the pavement appears to show the condition and the effect on his life in a way that everyone can understand and sympathize.
Unsurprisingly and self-evidently, obsessive–compulsive disorder (OCD) is indicated by the presence of either obsessions and/or compulsions and is a clinically heterogeneous condition. In the most recent International Classification of Diseases (10th Edition) of the World Health Organization, a diagnosis of OCD is indicated if the obsessive and/or compulsive behaviour is present on most days for at least two weeks. To be classed as having OCD, the behaviour(s) must cause significant distress or interfere with a person’s social and/or individual functioning (typically by time wasting). Other psychiatric disorders (e.g., Tourette’s syndrome, depression, schizophrenia) may include OCD behaviours. Furthermore, the World Health Organization ranks OCD as in the top ten most handicapping illnesses as measured by lost income and decreased quality of life.
The psychiatrist Dr David Veale (The Priory Hospital North London) and one the UK’s leading experts on obsessive-compulsive disorders, provides the following two definitions and classic features for compulsions and obsessions:
- Compulsions: These are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observed by others (e.g. checking that a light has been switched off) or a covert mental act that cannot be observed (e.g. repeating a certain phrase repeatedly in one’s mind). Covert compulsions are usually more difficult to resist than overt ones as they are viewed as ‘portable’ (and therefore easier to perform). A compulsion is not pleasurable for the person who experiences it. This differentiates it from impulsive acts such as shopping or gambling that are associated with immediate gratification
- Obsessions: These are defined as unwanted intrusive thoughts, images or urges that repeatedly enters the person’s mind. They are distressing (i.e. the person views the thoughts and/or behaviours as repugnant or inconsistent with their personality) but originate in the person’s mind and not imposed by an outside agency. Unwanted intrusive thoughts, images or urges are almost universal in the general population and their content (e.g., the urge to push someone over, the thought that the oven has been left on, etc.) is indistinguishable from clinical obsessions. However, the difference between a normal intrusive thought and an obsessional thought is the meaning that the person attaches to the occurrence and/or content of the intrusions.
Empirical research suggests that around 2% of the general population suffer from some form of OCD with a roughly equal gender split (although some OCD disorders are more male-based – such as sex and number obsessions – and some are more female based – such as compulsive hand washing). However, prevalence rates are dictated by the screening instruments used (some of which are claimed to over-inflate the problem). However, others claim that the prevalence rates are higher because some sufferers are simply too ashamed to seek the professional help they need.
In a study led by Dr Edna Foa (University of Pennsylvania, USA) on 431 people with OCD, the most common compulsions were checking things such as gas taps (28.8%), cleaning and washing (26.5%), repeating acts (11.1%), mental compulsions such as prayers being constantly repeated (10.9%), ordering, symmetry and/or exactness (5.9%), hoarding and collecting (3.5%), and constant counting (2.1%). The same study found that the most common obsessions were contamination from dirt, germs, viruses, bodily fluids or faeces, chemicals, sticky substances, and dangerous materials (37.8%), fear of harm (23.6%), excessive concern with order or symmetry (10%), obsessions with the body or physical symptoms (7.2%), religious, sacrilegious or blasphemous thoughts (5.9%), sexual thoughts such as being a paedophile or a homosexual (5.5%), urges to hoard useless or worn-out possessions (4.8%), and thoughts of violence or aggression such as stabbing one’s own baby (4.3%).
Similar findings were found in a study led by Dr David Mataix-Cols (Institute of Psychiatry, London) and published in the American Journal of Psychiatry. Following a comprehensive literature review, they reported 12 factor-analytic studies involving more than 2,000 OCD patients were identified. These studies typically showed at least four symptom dimensions. These were (i) symmetry and ordering, (ii) hoarding, (ii) contamination and cleaning, and (iv) obsessions and checking. They concluded that the complex clinical presentation of OCD can be summarized with these few consistent, temporally stable symptom dimensions.
Scientific research has shown that OCD typically develops in early adulthood for females (i.e., in their early twenties) and in late adolescence for males, although children of both sexes can also suffer. Studies using twin and families suggest that genetic factors may also play a role in the expression of OCD although psychological factors are also important in the acquisition, development and maintenance of the disorder. There is also some evidence that OCD is associated with high intelligence. The seriousness and severity of OCD differs from one individual to the next Some people with OCD are able to hide it even from those most close to them. However, more often, OCD seriously affects relationships and can lead to irreconcilable breakdown. It can also disrupt the ability to work or study.
In relation to prognosis, both psychological interventions (e.g., cognitive-behavioural therapy) and pharmacotherapy may lead to a significant decrease in OCD symptoms for typical sufferers. However, symptoms can continue to persist even after treatment. A completely OCD symptom-free period following treatment is relatively uncommon.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Eddy, K.T., Dutra, L., Bradley, R. & Westen, D. (2004). A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clinical Psychology Review, 24, 1011-1030.
Foa, E.B., Kozak M J, Salkovskis P.M., Coles, M.E. & Amir, N. (1998). The validation of a new obsessive-compulsive disorder scale: The Obsessive-Compulsive Inventory. Psychological Assessment, 10, 206-214.
Hodgson R.J., Budd R. & Griffiths M.D. (2001). Compulsive Behaviours (Chapter 15). In H. Helmchen, F.A. Henn, H. Lauter & N. Sartorious (Eds) Contemporary Psychiatry. Vol. 3 (Specific Psychiatric Disorders). pp.240-250. London: Springer.
Mataix-Cols, D., Conceição do Rosario-Campos, M. & Leckman, J.F. (2005). A multidimensional model of Obsessive-Compulsive Disorder. American Journal of Psychiatry, 162, 228-238.
Rachman, S.J. & Hodgson, R. (1980). Obsessions and Compulsions. Englewood Cliffs, NJ: Prentice Hall.
Veale, D. (2004). Psychopathology of obsessive-compulsive disorder. Psychiatry, 3(6), 65-68.
