Sick note: A (very) brief overview of emetophilia

“I was drunk while out during New Year’s Eve and I saw a big heap of vomit. Normally this would make me vomit at the sight of it but because I was drunk I lay down on my side next to it and started licking it. I am worried because ever since this I have become addicted and I often go out in the early hours of the morning in the hope to discover vomit to fuel my addiction the more congealed the vomit the better” (Email enquiry to Yahoo! Answers, 2011)

To most people, the opening quote might seem quite sickening (no pun intended). Emetophilia (also called vomerophilia) is a rare paraphilia in which individuals are sexually aroused either by self-induced vomiting or watching others vomit (i.e., there is an erotic focus on the regurgitated contents of a person’s stomach). More specifically, emetophiliacs are reported to love vomiting on their sexual partners. This practice is sometimes referred to as a ‘Roman shower’ based on the often-quoted stories of Romans throwing up between courses so that they could eat even more, and the Roman ‘vomitoriums’.

However, Cecil Adams, in his column in The Straight Dope, briefly examined Roman ‘vomitoriums’ but went on to highlight what vomitoriums really were. Vomitoriums existed but were actually passageways in amphitheatres that opened into a tier of seats from below or behind. Adams claimed that “the vomitoria deposited mobs of people into their seats and afterward disgorged them with equal abruptness into the streets–whence, presumably, the name”. Adams went onto say that although the Romans were no strangers to vomiting, they never did so on purpose. Vomiting does appear to have been part of the fine-dining experience but not done between courses to make way for more space in the person’s stomach.

Although sex and vomiting are somewhat strange bedfellows especially as sex is typically pleasurable and vomiting is typically unpleasurable, there are a number of similarities (although these might be viewed as stretching it a little). Many internet sites quote the same three similarities that sex and vomiting both (i) trigger hormones to be released that make people feel better, (ii) are initiated by a reaction to a stimulus, and (iii) [for men at least] involve the expulsion of fluids through a bodily tube and out of a bodily orifice.

Emetophiles appear to be diverse in which element of vomiting is the most erotic and/or most important. For some, it is the act of vomiting itself that is arousing. For these particular paraphiliacs, it has been claimed that the ‘spasm, ejaculation, relief’ sequence in vomiting is erotically charged. For others, sexual arousal is caused by either just talking about, collecting photographs/videos, seeing, and/or hearing others vomiting. In extreme cases, some individuals may get sexually aroused by their partner actually vomiting on them. Other extreme emetophile practices include the induction of vomiting in a partner (that in some cases may be forced). In these cases involving force, there are certainly shades of dominance and sadism (or if the wish is to be vomited upon by others, submission and masochism). The internet certainly acts as a catalyst to bring these people together (check out http://vomitonline.com/indepth.html) and the internet may also fuel emetophiles’ interest in celebrity vomiting as there are now loads of vomiting scenes from television and films circulating online.

Freud, arguably psychology’s most prolific writer on psychosexual issues, described vomiting as a substitute for moral and physical disgust. However, to my knowledge there is only one academic paper in the sex literature on the topic. This was by the renowned American psychiatrist and psychoanalyst Professor Robert Stoller (1924-1991) who published a 1982 paper in the Archives of Sexual Behavior and claimed it was “a previously unreported aberration”. Although Stoller claimed that vomiting paraphilias can occur in both males and females, the three case studies he outlined were all female. He suggested that emetophilia may manifest itself in a variety of ways (real versus imagined; self versus others; facilitative versus obligatory). If individuals have a sexual attraction to the vomit itself (rather than the vomiting process), then the diagnosis would be fetishism.

The first case described a woman that didn’t actually vomit herself but claimed she could reach orgasm “by imagining someone vomiting in a hard, humiliating fashion”. The second woman experienced an orgasm every time she vomited. The third woman said that “vomiting for me is like an orgasm in that I’m tensed, I feel the intense flood of good feelings almost continually throughout the vomiting and experience relief and quiet warmth in my body when I’m finished. It is not identical to an orgasm. I do not feel it intensely in my genitals alone, but I do feel it there as well as the rest of my body and in my mouth”.

Professor Stoller noted that the problem with this particular paraphilia is that the accounts are not based on those requiring treatment and that the stories take on an almost mythic-like quality rather than being “true-to-life”. He went on to say that by “concentrating on exact, naturalistic data collecting would show us how much we do not know…erotic impulses are a never-ending source of ingenious, even wondrous constructions [and] almost every object or body function can be erotized”

No-one really knows how this particular paraphilia develops although the root of most paraphilias lie in maladaptive learning. One online site I came across (‘Frequently Asked Questions About Vomiting’) theorized that “vomiting was probably something either arousing or frightening to emetophiles at some point … it aroused powerful emotions, and the emetophile later called upon these emotions for purpose of sexual gratification”. Some allege that emetophilia is closely related to emetophobia (i.e., the fear of vomiting) since some of these individuals may have developed emetophilia as a result of emetophobia. The thinking here is that (somewhat ironically) many emetophiles continue to fear vomiting themselves despite the amount of time they spend fantasizing about other people vomiting.

No-one knows (empirically) how widespread the practice is and whether it is restricted to certain countries but I will leave you with another quote from an emetophile that I came across online:

“I believe that the way we are affected by our [vomiting] kink transcends international borders and cultural differences, and is something basic to our human nature. I feel strongly that emetophilia is more than ‘just’ a kink, and has deeper origins than most fetishes. However, as an English speaker on an English-speaking board it’s hard for me to confirm that, which is one of the reasons it’s so nice to hear from [non-English speaking emetophiliacs]. So far, everyone else who has posted is from the US, Europe and other Western cultures, but now we’re beginning to get a feel for how international our kink truly is.”

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

Further reading

Adams, C. (2002). Were there really vomitoriums in ancient Rome? The Straight Dope. November 1. Located at: http://www.straightdope.com/columns/read/2421/were-there-really-vomitoriums-in-ancient-rome

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

Freud, S. (1953). Studies on Hysteria (Standard Edition). London: Hogarth Press.

Stoller, R.J. (1982). Erotic Vomiting”, Archives of Sexual Behavior 11: 361-365 (1982).

Tech’s appeal: Is there a relationship between addiction to video games and slot machines?

Back in 1987, I began my PhD on slot machine addiction, and one thing that I began to notice as I spent the first few hours of (100s of hours) doing observational research in amusement arcades that there were many similarities between arcade slot machines and arcade video game machines. It wasn’t until 1991 that I finally did a comparative analysis of slot machine gambling and video game playing and published my observations in the Journal of Adolescence. In the intervening years I have published many papers examining the commonalities and similarities between these two behaviours and it wouldn’t surprise me if I am still writing about these issue in many years to come.

My initial insights into the existence of video game addiction arose out of the research I had been doing on slot machine addiction. Both slot machines and video game machines may be considered under the generic label of “amusement machines”. The main difference between the playing of video games and the playing of slot machines are that arcade video games are typically played to accumulate as many points as possible whereas slot machines are played (i.e., gambled upon) to accumulate money. In my 1991 paper, I (somewhat paradoxically) claimed that playing an arcade video game could be considered as a non-financial form of gambling.

Both types of machine require insertion of a coin to play, although the playing time on a slot machine is usually much less than on a video game machine if starting with the same amount of money. This is because on video games the outcome is almost solely due to skill, whereas on slot machines the outcome is much more likely to be a product of chance. However, the general playing philosophy of both slot machine players and video game players is to stay on the machine for as long as possible using the least amount of money. I have also argued that regular slot machine players play with money rather than for it, and that winning money is a means to an end (i.e., to stay on the machine as long as possible). This is exactly what arcade video game players do too.

Besides the generic labeling, their geographical juxtaposition, and the philosophy for playing, it could be argued that on both a psychological and behavioural level, slot machine gambling and video game playing share many similarities (e.g., similar demographic differences such as age and gender breakdown, similar reinforcement schedules, similar potential for “near miss” opportunities, similar structural characteristics involving the use of light and sound effects, similarities in skill perception, similarities in the effects of excessive play, etc.). The most probable reason the two forms have rarely been seen as conceptually similar is because video game playing does not involve the winning of money (or something of financial value) and therefore cannot be classed as a form of gambling.

However, the next generation of slot machines is starting to use video game graphics and technology. While many of these relate to traditional gambling games (e.g., roulette, poker, blackjack, etc.) there are plans for developing video gambling games in which people would win money based on their game scores. This obviously gives an idea of the direction that slot machines and the gaming industry are heading.

Furthermore, there are a growing number of researchers who suggest that video games share some common ground with slot machines including the potential for dependency. On 1995, Dr Sue Fisher and myself edited a special issue of the Journal of Gambling Studies and wrote a paper examining trends in slot machine gambling. We pointed out that arcade video games and slot machines shared some important structural characteristics, these being:

• The requirement of response to stimuli that are predictable and governed by the software loop.
• The requirement of total concentration and hand–eye coordination.
• Rapid span of play negotiable to some extent by the skill of the player (more marked in video games).
• The provision of aural and visual rewards for a winning move (e.g., flashing lights, electronic jingles).
• The provision of an incremental reward for a winning move (points or money) that reinforces “correct” behaviour.
• Digitally displayed scores of “correct behaviour” (in the form of points or money accumulated).
• The opportunity for peer group attention and approval through com- petition.

As with excessive slot machine playing, excessive video game playing partly comes about by the partial reinforcement effect. This is a critical psychological ingredient of video game addiction whereby the reinforcement is intermittent – that is, people keep responding in the absence of reinforcement hoping that another reward is just around the corner. Knowledge about the partial reinforcement effect gives the video game designer an edge in designing appealing games. Magnitude of reinforcement is also important. Large rewards lead to fast responding and greater resistance to extinction – in short to more “addiction.” Instant reinforcement is also satisfying.

Video games rely on multiple reinforcements (i.e., what I call the “kitchen sink” approach) in that different features might be differently rewarding to different people. Success on video games comes from a variety of sources and the reinforcement might be intrinsic (e.g., improving a personal high score, beating a friend’s high score, putting a name on the “hall of fame,” mastering the machine) or extrinsic (e.g., peer admiration). As early as the 1980s, Dr. Thomas Malone reported that video game engagement is positively correlated to (i) a presence or absence of goals, (ii) the availability of automatic computer scores, (iii) the presence of audio effects, (iv) the random quality of the games, and (v) the degree to which rapid reaction times enhance game scores.

In 2007, Dr Jonathan Parke (Salford University, UK) and I developed a new taxonomy of structural characteristics related to gambling, listing all the known structural characteristics that have been shown to influence gambling behaviour in some way. All the 60+ structural characteristics were grouped into one of six types of characteristic:

• Speed and frequency characteristics: Factors relating to the frequency, duration and expediency of the game or reward.
• Playability characteristics: Factors that make gambling fun, interaction and/or engaging.
• Payment characteristics: Factors that relate to how one pays to gamble
• Reward characteristics: Factors relating to how one receives financial rewards or winnings.
• Educational characteristics: Factors that educate, protect, or provide information to players.
• Ambient characteristics: Factors that may influence the immediate situation of the game or may contribute to other factors already mentioned (e.g., the use of colour and sound).

Using this typology, Dr Parke and I argued that future research and policy initiatives may be to focus on regulating structural factors relating to payment (spending) and player awareness/education and focus less on structural factors relating to playability (which may also include reward, ambient, and speed characteristics). In this way, slot machines can continue to be fun, exciting, and play inducing, but with the eventual aim of minimizing harm.

It wasn’t until 2010 that I – along with Dr Daniel King and Dr Paul Delfabbro (both at the University of Adelaide, Australia) – developed a separate taxonomy of structural characteristics related to video game playing (published in the International Journal of Mental health and Addiction). We used some earlier empirical work that I had done with Dr Richard Wood (GamRes Ltd, Canada) back in 2004 and published in the journal CyberPsychology and Behavior. We devised a list of structural features by (a) playing a variety of video games, (b) examining and comparing known gambling structural characteristics, (c) discussing these features with players of video games, and (d) examining relevant research in the area of video game design. Our framework included the following characteristics:

• Sound, including sound effects, speaking characters and background music.
• Graphics, including high-quality realistic or cartoon-style graphics and full motion video (FMV).
• Background and setting, including whether the game is based on a story, film, or television program, and the use of realistic or fantasy settings.
• Duration of game, referring to how long the game usually takes to complete.
• Rate of play, referring to how quickly the player “absorbs” or “gets into” the game. & Advancement rate, referring to how quickly the game play advances.
• Use of humour in the game.
• Control options, referring to what the player can control in the game (including sound, graphics, and skill settings, choice of control methods, and physical feedback). &
• Game dynamics, including exploring new areas, elements of surprise, fulfilling a quest, skill development, AI interactions, collecting things, avoiding things, surviving against the odds, shooting, different ending options, different modes of transport, solving puzzles, beating times, cheats/Easter eggs, solving time limited problems, building environments, mapping, and linear/non-linear game format.
• Winning and losing features, referring to the potential to gain or lose points, finding bonuses, having to start level again, and ability to save regularly.
• Character development, referring to character development over time and character customization options.
• Brand assurance, referring to brand loyalty and/or celebrity endorsement.
• Multiplayer features, referring to various multi-player options, communication methods, building alliances, and beating other players.

Using this paper, and the gambling structural characteristics taxonomy, we developed our new video game structural characteristics taxonomy comprising five types of feature. These were: (a)

• Social features (i.e., social aspects of video game playing)
• Manipulation and control features (i.e., the role of user input in influencing in-game outcomes)
• Narrative and identity features (e.g., the role of character creation and interactive storytelling)
• Reward and punishment features (i.e., the ways in which players win and lose in video games)
• Presentation features (e.g., the visual and auditory presentation of video games).

Since developing the taxonomy, we have started to test it out empirically. Dr. King, Dr. Delfabbro and myself recently published a study investigating our structural characteristic taxonomy among 421 video game players (aged between 14 and 57 years). Our results showed that the reward and punishment features, such as earning points, finding rare game items, and fast loading times, were rated among the most enjoyable and important aspects of video game playing. There was some evidence that certain structural characteristics were stronger predictors of problematic involvement in video games than factors such as gender, age, and time spent playing. This included the use of adult content in the game, earning points, getting 100% in the game, and mastering the game. Our latest research supports the notion that some structural characteristics in video games may play a significant role in influencing problem video game playing behaviour.

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

Further reading

Fisher, S.E., & Griffiths, M.D. (1995). Current trends in slot machine gambling: Research and policy issues. Journal of Gambling Studies, 11, 239-247.

Griffiths, M.D. (1991). The observational analysis of adolescent gambling in UK amusement arcades. Journal of Community and Applied Social Psychology, 1, 309-320.

Griffiths, M.D. (1991). Amusement machine playing in childhood and adolescence: A comparative analysis of video games and fruit machines. Journal of Adolescence, 14, 53-73.

Griffiths, M.D. (1995). Adolescent gambling. London: Routledge.

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

Griffiths, M.D. (2005). The relationship between gambling and videogame playing: A response to Johansson and Gotestam. Psychological Reports, 96, 644-646.

Parke, J. & Griffiths, M.D. (2007). The role of structural characteristics in gambling.  In G. Smith, D. Hodgins & R. Williams (Eds.), Research and Measurement Issues in Gambling Studies. pp.211-243. New York: Elsevier.

Griffiths, M.D. (2011).  A typology of UK slot machine gamblers: A longitudinal observational and interview study. International Journal of Mental Health and Addiction, 9, 606-626.

King, D.L., Delfabbro, P.H., Derevensky, J. & Griffiths, M.D. (2012). The classification of video games with gambling themes and content: An Australian perspective. International Gambling Studies, in press.

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2010). Video game structural characteristics: A new psychological taxonomy. International Journal of Mental Health and Addiction, 8, 90-106.

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

King, D.L., Delfabbro, P.H. & Griffiths, M.D. (2011). The role of structural characteristics in problematic video game play: An empirical study. International Journal of Mental Health and Addiction, 9, 320-333.

Malone, T.W. (1981). Toward a theory of intrinsically motivating instruction. Cognitive Science, 4, 333–369.

Baby love: A beginner’s guide to paraphilic infantilism

Paraphilic infantilism is a rare sexual paraphilia where individuals typically get sexually aroused from being a baby (and is commonly referred to as ‘adult baby syndrome’). Some websites claim that the condition also goes under the name of ‘autonepiophilia’ but the sexologist who coined this particular paraphilia (Professor John Money) described the condition as particularly relating to ‘diaper fetishism’ (i.e., people who get sexually aroused from wearing nappies). At present, infantilism does not appear in any diagnostic psychiatric texts in its own right (such as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]). However, as Dr Joel Milner, Dr Cynthia Dopke, and Dr Julie Crouch note in a 2008 review of paraphilias not otherwise specified (NOS):

“Although infantilism is classified as sexual masochism in DSM-IV it is questionable whether the criteria for sexual masochism are always met. For example, if the infantile role playing does not involve feelings of humiliation and suffering, then the diagnosis of sexual masochism would not be appropriate and a diagnosis of infantilism as paraphilia NOS is warranted”.

Infantilists often wear nappies, may drink from a baby bottle and/or be wet-nursed (sometimes simulated), crawl about the floor, have baby baths, eat baby foods, play with baby toys, be spanked, and may roleplay and regress to an infant-like state. There may also be some crossover with other sexually paraphilic behaviour including masochism (as they may enjoy being spanked and/or humiliated), transvestism (as they may like to be dressed in baby clothes of the opposite sex, the so-called “sissy baby” syndrome), urophilia (as they may enjoy urinating in their nappies), coprophilia (as they may enjoy defecating in their nappies), and lactophilia (as they may enjoy being breast fed).

Up until 1980, there were only three published case studies on infantilism all in the American Journal of Psychiatry between 1964 and 1967. Malitz reported a case of a 20-year-old college student who had a compulsion to wear nappies underneath rubber pants and defecate in them (although did not see himself as an adult baby). While defecating he would typically reach orgasm even if he didn’t masturbate. Tuchman and Lachman reported the case of a father who was arrested for molesting his young daughters. Like the first case, he wore rubber pants over his nappy and enjoyed urinating and masturbating in it. Dinello reported the case of a 17-year-old male who in his mid-teens started wearing nappies under his clothing, drank from baby bottles, and ate baby food, and masturbated while wearing the nappy. He eventually, gave up wearing nappies and began dressing in women’s clothing. In a 1980 issue of the Medical Journal of Australia, Pettit and Barr published the case of 24-year-old man who began dressing in female clothes at the age of 10 years and by the age of 15 years began to dress as a baby and developed a fetish for nappies.

In a more recent issue of American Journal of Psychiatry, Dr Jennifer Pate and Dr Glenn Gabbard presented a case study showing many similarities with the earlier published case studies. Their case study was a 35-year-old single man who wanted to be a baby since the age of 12 years and he began wearing nappies at age 17 years. His nappy wearing had started to compromise his interpersonal relationships. Wearing nappies was “a kind of a sexual thing” and he masturbated while wearing the nappies. He only ever masturbated while wearing nappies, and also urinated and defecated while wearing them. He wore and used up to five nappies a day. Pate and Gabbard concluded that the object of sexual arousal was the nappies and that the behaviour was a paraphilia. More specifically, they said:

“Adult baby syndrome is still a new entity for psychiatrists, and there are undoubtedly variations within the syndrome. [One of the cases said] that he wanted someone to ‘make him be a baby’ evokes images of the sadomasochistic scenarios enacted by a dominatrix and her clients. Indeed, a significant number of middle-aged men seek out dominatrices to spank them, punish them, and tell them that they have been ‘a bad boy’. The wish to be treated as a baby is probably a spectrum condition that has many manifestations involving men, women, heterosexuals, bisexuals, and homosexuals”.

Other recent case studies have noted different etiological pathways into infantilism with childhood sexual abuse and transgender issues being apparent common factors among a number of published case studies. In a 2003 issue of the journal Sexual Abuse, Lehne and Money reviewed the case of a man with changing fetishes (transvestic fetishism, paedophilia) who in the final analysis described himself an adult baby (aged 45 years). In 2004, Croarkin and colleagues reported a case in the American Journal of Psychiatry. Here, a depressed 32-year-old male engaged in behaviours that included getting sexual arousal and gratification from wearing nappies and becoming a baby. The authors suggested that the infantilism may have been related to obsessive-compulsive disorder. Two years later in the Archives of Sexual Behavior, Evcimen and Gratz reported the case of a 25-year-old male who wished to be a 10-year-old girl although it is debatable whether this case would really be classed as infantilism.

The most recent case (2011) of ‘adult baby syndrome’ was reported by Kise and Nguyen in the Archives of Sexual Behavior. They outlined the detailed case a 38-year-old biological male who preferred to be identified as a female (and referred to him as ‘she’ throughout their paper). For the previous two years, she slept in a crib (rather than a bed), drank from baby bottles, sucked on dummies, and engaged in baby talk (and had wanted to be a baby since her early thirties). She suffered from Guillain-Barre Syndrome (a disorder affecting the peripheral nervous system) and had been a paraplegic since the age of 13 years following a complication from a tracheotomy. She was sexually abused as a child and had attempted suicide 28 times. Kise and Nguyen concluded:

“Perhaps desiring the identity of a baby is an entity all in itself, just like Major Depressive Disorder or Schizophrenia…This does not represent a new phenomenon…In some instances, [Adult Baby Syndrome] seems to represent a paraphilia. [In this case] she specifically denied sexual pleasure…her primary intent seems to be one of gaining attention and additional care, freeing her from adult responsibilities. Further investigation into the connection and potential co-morbidity between ABS and Gender Identity Disorder may lead to interesting findings”.

One of the few surveys (from an unpublished PhD thesis on the topic by Dr Thomas Speaker) reported that infantilists are typically male, employed, in their late thirties, well educated, and in stable sexual relationships. However, no-one knows how representative of infantilists the survey was. The two criminologists Stephen Holmes and Ronald Holmes have claimed that infantilism may involve an elements of stress reduction similar to some of the symptoms of transvestism.

Nothing is known about the incidence or prevalence of infantilism, and there is no consensus on the etiology of infantilism but has been linked to maladaptive learning in childhood, faulty childhood imprinting, and erotic targeting errors. For others, the sexual element may be downplayed. Such individuals may want to be gently nurtured, seek attention, be cared for and/or surrender their day-to-day adult life responsibilities.

One of the reasons so little is known about infantilism is that adult babies do not want to cease engaging in their behaviour. For most adult babies, their behaviour doesn’t constitute a medical condition that requires treatment or cause any functional impairment, personal distress or distress to others. Those who do end up seeking psychological or psychiatric help may do so because another individual (such as their sexual partner) encourages or forces them to seek help.

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

Further reading

Croarkin, P., Nam, T., & Waldrep, D. (2004). Comment on adult baby syndrome. American Journal of Psychiatry, 161, 2141.

Dinello, F.A. (1967). Stages of treatment in the case of a diaper-wearing seventeen-year-old male. American Journal of Psychiatry, 124, 94-96.

Evcimen, H., & Gratz, S. (2006). Adult baby syndrome. Archives of Sexual Behavior, 35, 115–116.

Holmes, Ronald M.; Holmes, Stephen T. (2008). Sex Crimes: Patterns and Behavior. New York: Sage.

Kise, K. & Nguyen, M. (2011). Adult Baby Syndrome and Gender Identity Disorder. Archives of Sexual Behavior, 40, 857-859.

Lehne, G. K. & Money, J. (2003). Multiplex versus multiple taxonomy of paraphilia: Case example. Sexual Abuse: A Journal of Research and Treatment, 15, 61-72.

Malitz, S (1966). Another report on the wearing of diapers and rubber pants by an adult male. American Journal of Psychiatry, 122, 1435-1437.

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

Money, J. (1984). Paraphilias: Phenomenology and classification”. American Journal of psychotherapy, 38, 164–179

Pate, J. & Gabbard, J.O. (2003). Adult baby syndrome. American Journal of Psychiatry, 160, 1932-1936.

Pettit, I., & Barr, R. (1980). Temporal lobe epilepsy with diaper fetishism and gender dysphoria. Medical Journal of Australia, 2, 208-209.

Speaker, TJ, Psychosexual Infantilism in Adults: The Eroticization of Regression, Sausalito, CA: Columbia Pacific University (Unpublished PhD thesis).

Tuchman, W.W. & Lachman, J.H. (1964). An unusual perversion: the wearing of diapers and rubber pants in a 29-year-old male. American Journal of Psychiatry, 120, 1198-1199.

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.

Urine demand: A beginner’s guide to urophilia

In an earlier blog, I examined coprophilia (i.e., a paraphilia in which people are sexually aroused by faeces). Another related paraphilia is urophilia in which people are sexually aroused by urine (i.e., the sight or thought of either the act of urination or the urine itself). The condition is known by many different names. In scientific circles it can also be called urophagia, urolagnia, renifleurism, undinism, and ondinisme. In non-scientific circles it is more popularly called ‘water sports’, ‘golden showers’ and (most crudely) ‘piss play’. This has also led to dedicated websites where ‘pee lovers’ can meet up.

Press reports have reported a few celebrities engaging in the activity. For instance, in an interview with the music magazine Blender, the Puerto Rican popstar Ricky Martin stated that he enjoyed ‘golden showers’. The actor Andy Milonakis and host of MTV’s ‘The Andy Milonakis Show’ said in an interview with People Magazine that liked the feeling of “warm urine” on his chest during sexual intercourse. Interestingly, it was recently discovered that Havelock Ellis – one the ‘founding fathers’ of sexology – was aroused by the sight of a woman urinating.

“In childhood, as his autobiography reveals, Ellis had exclusive attention from his mother during long absences of his sea captain father. Ellis was the eldest child and only son, whose intimacy with his mother included sponging her back and being present when he was twelve and older as she urinated. (His sister, when she heard of one incident, thought that their mother was being flirtatious, since normally she was rather a reserved person.) The consequences of this malimprinting Ellis dignified with the term urolagnia, which he denied had become a real perversion or a dominant interest in his sexual life. His candour had limits, and the evidence is otherwise… In Ellis’s instance the trauma of witnessing his mother urinate was converted into the hostile pleasure of humiliating other women, women in no way connected with his mother, by persuading them to do something for reasons mainly unintelligible to them. When he had the gratification of inducing Franroise [his partner] to urinate in crowded Oxford Circus, she may not have felt especially humiliated. With such an initiate his satisfaction was mainly symbolic…The perversion was enough on his mind for him to write it into his seventh volume of Studies in the Psychology of Sex. There he dignifies the pathological sounding “urolagnia” with the new and enticing term “undinism”. Grosskurth thinks that this volume came into existence principally to defend the perversion which is not discussed elsewhere” (Andrew Brink’s book review of Phyllis Grosskurth’s biography of Havelock Ellis, 1980).

In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (and like coprophilia), urophilia is listed as a ‘paraphilia not otherwise specified’ (PNOS). As with all paraphilias in the PNOS category, diagnosis is only made “if the behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning…Fantasies, behaviors, or objects are paraphilic only when they lead to clinically significant distress or impairment (e.g., are obligatory, result in sexual dysfunction, require participation of non-consenting individuals, lead to legal complications, interfere with social relationships)”.

Urophiliacs typically derive sexual pleasure from urinating on (and/or being urinated upon by) another person. Some urophiliacs may also bathe in urine, enjoy smelling people in urine-soaked clothes, and/or engage in urophagia (i.e., drinking the urine). For urophiliacs, the drinking of the urine typically takes place while someone else urinates directly into their mouth. Urophagia (in and of itself) is not necessarily a sexually arousing activity as there are many urine drinkers who don’t do it for sexual pleasure but for other reasons (e.g., ritualistic and ceremonial purposes or they think there are health or cosmetic benefits as witnessed by those who engage in ‘urine therapy’).

However, for urophiliacs, the act of urophagia may be sexually stimulating for them. They may also engage in the activity as part of other paraphilic activity such as sadism, masochism, voyeurism, and infantalism (i.e., being sexually excited from dressing as an adult baby). Some urophiliacs may also experience sexual arousal from having a full bladder and/or feel sexually attracted to someone else who has a full bladder (‘bladder desperation’) or wets themselves (i.e. ‘panty wetting’ or wetting the bed). In Japan, this latter parahilic behaviour occurs as part of a fetish subculture known as ‘omorashi’ and is seen as different from urophilia.

In 2009, Dr Garth Mundiger-Klow (Beverly Hills Institute of Sexual Health Research, USA) published a whole book comprising 15 urophiliac case studies (The Golden Fetish) but despite the academic credentials of the author, and the lengthy accounts, the book was little more than a collection of erotic stories based around urophiliacs with little analysis provided by the author.

To date, there has been very little scientific research and almost all of what is known is based on either case studies or as a co-occurring behaviour with other paraphilias. For instance, in a survey of 561 non-incarcerated individuals seeking treatment for paraphilias, Dr Gene Abel, and colleagues found that many paraphiliacs engaged in more than one paraphilic behaviour. For instance, all the zoophiles in the sample reported more than one paraphilia and for a small number this included urophilia. However, it appears that urophilia is mostly likely associated with sadomasocism. For instance, in a study of 245 male sadomasochists, Dr Andreas Spengler (University of Hamburg, Germany) reported that 10% of those surveyed had an interest in urophilia. This finding is similar to that of Dr Neil Buhrich (St. Vincent’s Hospital, New South Wales, Australia) who found that 8% of his sample of sadomasichists reported an interest in urophilia.

A paper in a 1982 edition of the Canadian Journal of Psychiatry by Dr R. Denson found that the urine fulfilled many different functions for urophiles. The functions of urine included it (i) serving as a fetishistic object, (ii) being used to humiliate or be humiliated (i.e., through urinating on another person or being urinated upon), and/or (iii) capturing the spirit of a sexual partner. Based on the case studies examined, Dr Denson also argued that urination may serve masochistic and/or sadistic purposes and that therefore it should be labeled ‘uromasochism’ or ‘urosadism’.

While most explanations for paraphilic urophilia focus on early behavioural conditioning in childhood and adolescence, I also came across an interesting snippet in Professor John Money’s 1980 book Love and Love Sickness: The Science of Sex, Gender Difference and Pair-bonding:

“Some years ago, when I visited the Yerkes primate laboratory in Atlanta…How, I asked, did a wild chimpanzee mother keep its baby clean from soiling? The answer was that, as in many other species, she licks it clean…Among the people of Bali, in Indonesia, small dogs lick the babies clean…The dog’s assigned duty is to provide diaper service by licking clean the baby, and the mother, whenever the baby soils. Subsequently I have learned that Eskimo mothers once had a custom of licking their babies clean. Even though human primates have graduated from using the mother’s snout end to keep the baby’s tail end clean, it is safe to assume that, as a species, we still possess in the brain the same phyletic circuitry for infant hygiene as do the subhuman primates. Just as males and females have nipples, so also do both sexes have these brain pathways that relate to drinking urine and eating feces. These are the pathways that, when they become associated with neighboring erotic/sexual pathways, produce urophilia and coprophilia as paraphilias”.

Additionally, an internet essay examining ‘forced retention of bodily waste’ among children, Laurie Couture makes the following observations in relation to the origin of urine-related paraphilias:

“Some sufferers of forced waste retention develop sexual fetishes involving waste and waste retention…adult respondents reported using masturbation as a way to dissociate from the pain of a full bladder. Websites that cater to the sadomasochistic desires of urolagnia (“water sports”) enthusiasts are prevalent on the Internet…Adults who engage in urolagnia are often reenacting scenes from childhood, some of which involved denial of toilet use by school teachers or caretakers for purposes of punishment or containment…Due to the close proximity of the urethra and bladder to the sex organs, some adults who chronically suffered this form of bodily control as children developed a conditioned response in which wetting themselves or bladder tension was association with sexual arousal”

Clearly, there is still much to learn in this area but there are certainly some interesting speculations as to the origins and initiation of urophilic behaviour.

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

Further reading

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

Buhrich, N. (1983). The association of erotic piercing with homosexuality, sadomasochism, bondage, fetishism, and tattoos. Archives of Sexual Behavior, 12, 167-171.

Collacott, R.A. & Cooper, S.A. (1995). Urine fetish in a man with learning disabilities. Journal of Intellectual Disability Research, 39, 145-147.

Couture, L.A. (2000). Forced retention of bodily waste: The most overlooked form of child maltreatment. Located at: http://www.nospank.net/couture2.htm

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

Grosskurth, P. (1980). Havelock Ellis: A Biography. Toronto: McClelland and Stewart.

Massion-verniory, L. & Dumont, E. (1958). Four cases of undinism. Acta Neurol Psychiatr Belg. 58, 446-59.

Money, J. (1980). Love and Love Sickness: The Science of Sex, Gender Difference and Pair-bonding, John Hopkins University Press.

Mundinger-Klow, G. (2009). The Golden Fetish: Case Histories in the Wild World of Watersports. Paris: Olympia Press.

Skinner, L. J., & Becker, J. V. (1985). Sexual dysfunctions and deviations. In M. Hersen & S. M. Turner (Eds.), Diagnostic interviewing (pp. 211–239). New York: Plenum Press.

Spengler, A. (1977). Manifest sadomasochism of males: Results of an empirical study. Archives of Sexual Behavior, 6, 441–456.

Acting up: Do gambling films accurately portray pathological gambling?

The media undoubtedly has a large impact on how we perceive the world in which we live, especially on matters we know little or nothing about. Pathological gambling is one social concern that has been portrayed by a number of movie-makers around the world, although the depth to which each film explores the issue differs greatly. The world of gambling and gamblers has been portrayed in many films and in many different ways throughout the years (e.g., The Sting, The Cincinnati Kid, Casino, Owning Mahoney, Rain Man). However, I argued in a 1989 issue of the Journal of Gambling Behavior that many of these film representations tend to cast gambling in an innocuous light, and often portray gamblers, largely male, as hero figures.

One film that has dealt entirely with the downside of gambling is The Gambler (1974; directed by Karel Reisz), and starring James Caan in the lead role as Professor Alex Freed, a university lecturer in literature and a compulsive gambler. The film is probably the most in-depth fictional film about the life of a pathological gambler. Back in 2004, I published an academic paper in the International Journal of Mental Health and Addiction on this film and assessed the extent to which the film accurately portrayed the “typical” pathological gambler by using the diagnostic criteria for pathological gambling in the last three editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. I concluded that the film accurately portrayed most of the criteria in the DSM-III, the DSM-III-R, and the DSM-IV. In addition, I also examined other parts of the film’s text and scenarios to examine the film’s theoretical perspective and its relevance to contemporary representations of pathological gambling.

The start of the film sees Freed go into $44,000 debt after gambling and losing at blackjack, craps and roulette in a casino. The film’s main story revolves around Alex’s attempt to pay back his debt to mobsters. His mother, a doctor, gives him the money that he then gambles away almost immediately through sports betting. Faced with no money to pay the mobsters, and no family to bail him out, he cancels his debt by illegally fixing a basketball game for the mobsters with the help of one of his students who is on the basketball team. The film’s main theme, aside from pathological gambling, is Freed’s masochistic tendency that is highlighted in the final scene. Here, Freed walks into a white “no-go” area of New York, walks into a bar, hires a prostitute, refuses to pay her and is then confronted by her knife-wielding pimp who he dares to kill him. Freed then batters the pimp, but is cut across the face by the prostitute using her pimp’s knife. The film ends with Freed leaving the room with a heavily bleeding face.

When Freed is asked by his girlfriend why he gambles to excess, he responds:

“It’s just something I like to do. I like the uncertainty of it … I like the threat of losing…the idea that…uh…I could lose but that somehow I won’t because I don’t want to…that’s what I like… and I love winning even though it never lasts”.

This reply by Freed, to some extent, hints at the film’s outlook on pathological gambling. However, the film’s basic premise is that gamblers gamble because they want to lose, thereby partially adhering to Edmund Bergler’s [1957] psychodynamic account of gambling. Bergler extended Freud’s ideas about guilt-relief in losing, and argued that gambling is a rebellious act, an aggression against logic, intelligence, moderation and morality. Ultimately, gambling is the denial of parental authority – a denial of the reality principle (i.e., even the gambler’s parents – who symbolize logic, intelligence and morality – cannot predict a chance outcome). According to Bergler, the unconscious desire to lose arises when gambling activates forbidden unconscious desires (e.g., parricidal feelings). The financial loss provides the punishment to maintain the gambler’s psychological equilibrium. According to this view, gambling is, in essence, masochistic. While the psychodynamic perspective highlights the fact that reasons for gambling may involve unconscious desires, there is very sparse in contemporary research literature that supports Bergler’s theoretical perspective on gambling.

In the course of the film, the viewpoint that gambling is masochistic and motivated by a desire to lose is forwarded only once in a conversation by Freed and ‘Hips’, one of the mobsters who is also one of Freed’s friends:

Hips: “Listen, I’m gonna tell you something I’ve never told a customer before. Personally I’ve never made a bet in my life. You know why? Because I’ve observed first hand what we see in the different kinds of people that are addicted to gambling, what we would call degenerates. I’ve noticed there’s one thing that makes all of them the same. You know what that is?”

Freed: “Yes. They’re all looking to lose” Hips: “You mean you knew that?”

Freed: “I could have wiped the floor with your ass” Hips: “Yeah? How?”

Freed: “By playing just the games I knew I’d win”

Hips: “Then why didn’t you?”

Freed: “Listen, if all my bets were safe there just wouldn’t be any juice”

The masochistic tendencies run throughout the film until the very final scene. However, another interpretation was put forward by psychologists Dr Richard Rosenthal and Dr Lori Rugle in a 1994 issue of the Journal of Gambling Studies. These authors said that there is a group of gamblers for whom it is not winning that is all-important, but losing. According to an earlier paper by Dr Rosenthal, it is the risk of getting hurt and losing everything that is exciting for them (i.e., “living on the edge”), which he described as omnipotent provocation. Such omnipotent provocation is akin to a deliberate flirting with fate (and danger) to prove one is in control. Rosenthal and Rugle argue this thesis on the basis of the final scene from The Gambler:

“In the climactic scene, the compulsive gambler-protagonist…walks the streets of Harlem, alone and at night, fully aware of the taunts and the threats that follow him. He enters a bar and provokes a fight with a prostitute and her knife-wielding pimp. After getting slashed, he staggers out, blood pouring from his face. In the final frame, he has stopped to look in the mirror, and while examining what will soon be a huge scar, he smiles. His expression says it all. He has gone to the edge, escaped with his life, and that, for him, is a big win”.

From the synopsis of the film presented above, it could be argued that, for Alex Freed, life in itself was one big gamble. Although the theme of desired losing is the film’s message, the desire to lose is suppressed when Freed talks to most people. To his students, Freed intellectualizes his gambling using the work of Dostoevsky (who was indeed a pathological gambler himself). For instance, quoting from Notes from Underground (Dostoevsky, 1864), Freed lectures his students on reason and rationality. Although not alluding to gambling, he quotes Dostoevsky’s assertion:

“Reason only satisfies man’s rational requirements, desire on the other hand accompanies everything, and desire is life”.

To others around him (i.e., his family, girlfriend, fellow gamblers, and bookmakers), much of Freed’s gambling talk is bravado. For instance, just as he is about to pay his debt to the mobsters with the money his mother had given him, he takes an impulse trip to Las Vegas with his girlfriend.

My analysis of the film The Gambler argued that the Freed character is a fairly accurate representation of a pathological gambler and of what is known about pathological gambling. There is anecdotal evidence that pathological gamblers identify with the film and that it is an accurate portrayal-at least of the typical male gambler seen in treatment. The actions of Alex Freed (e.g., pre-occupation with gambling, deterioration of relationships due to gambling, gambling to win back losses, and illegal acts performed to solve problems) are (a) familiar to anyone who encounters pathological gamblers in either a professional or personal capacity, and (b) would be similar to any pathological gambler, regardless of the rhetorical justifications and subjective motivations (i.e., excessive gamblers will display the same observable behaviour despite different etiological roots or theoretical perspectives). If The Gambler was the only film regarding pathological gambling that the general public ever saw, then it is fair to say they would go away with a good perspective on what pathological gambling is and what it can do to people. What the film does not adequately do is explain that there is more than one reason as to why people might gamble excessively.

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

Further reading

Bergler, E. (1957). The psychology of gambling. New York: Hill & Wang, Inc.

Griffiths, M.D. (1989). Gambling in children and adolescents. Journal of Gambling Behavior, 5, 66-83.

Griffiths, M. (2004). An empirical analysis of the film ‘The Gambler’. International Journal of Mental Health and Addiction, 1(2), 39-43.

Rosenthal, R. J. (1986). The pathological gambler’s system for self deception. Journal of Gambling Behavior, 2, 108- 120.

Rosenthal, R. J., & Rugle, L. J. (1994). A psychodynamic approach to the treatment of pathological gambling: Part 1. Achieving abstinence. Journal of Gambling Studies, 10, 21-42.

The bite of passion: Vampirism as a sexual paraphilia

Although vampirism as a sexual paraphilia has been noted in the academic literature for many years (in fact there are references to it in Richard van Krafft-Ebing’s 1886 text Psychopathia Sexualis), there has been very little empirical research and most of what is known comes from clinical case studies. To complicate things further, vampirism (i) is rarely a single clinical condition, (ii) may or may not be associated with other psychiatric and/or psychological disorders (e.g., severe psychopathy, schizophrenia, hysteria, mental retardation), and (iii) may or may not necessarily include sexual arousal. Other related conditions have been documented such as odaxelagnia (deriving sexual pleasure from biting), haematolagnia (deriving sexual satisfaction from the drinking of blood), and haematophilia (deriving sexual satisfaction from blood in general), and auto-haemofetishism (i.e., deriving sexual pleasure from sight of blood drawn into a syringe during intravenous drug practice).

In 1964, Vandenbergh and Kelly defined vampirism as “the act of drawing blood from an object, (usually a love object) and receiving resultant sexual excitement and pleasure”. In 1983, Bourguignon described vampirism as a clinical phenomenon in which myth, fantasy, and reality converge and that other paraphilic behaviour may be involved including necrophagia, necrophilia, and sadism. Also in 1983, noted that “vampirism is a rare compulsive disorder with an irresistible urge for blood ingestion, a ritual necessary to bring mental relief; like other compulsions, its meaning is not understood by the participant”.

In 1985, Herschel Prins published what is arguably the most cited paper in the field (in the British Journal of Psychiatry), and proposed that there were four types of vampirism (although confusingly, one of these sub-types is not actually vampiric as no blood ingestion takes place and some of the satisfaction gained may not necessarily be sexual). These four types were:

• Necrosadistic vampirism (i.e., deriving satisfaction from the ingestion of blood from a dead person);
• Necrophilia (i.e., deriving satisfaction from sexual activity with a dead person without the ingestion of blood)
• Vampirism (i.e., deriving satisfaction from the ingestion of blood from a living person)
• Autovampirism (deriving satisfaction from the ingestion of one’s own blood).

In Prins’ typology above, vampirism evidently overlaps with that of necrophilia. However, earlier papers (such as Vandenbergh and Kelly’s in 1964) clearly differentiated between necrophilia and vampirism, arguing that vampirism shouldn’t be mixed with necrophilia given that vampirism is often focused on the living. Vandenbergh and Kelly also differentiate vampirism from sexual sadism (due to the fact that vampirism doesn’t always include pain and suffering). In fact, in a literature review of sexual sadism, Yates and colleagues (2008) included the “rare phenomenon” of vampirism in their review. Drawing on the work of Jaffe and DiCataldo (1994), they described those people who get sexual arousal from bloodletting (either through cutting or biting), and for which a small minority enjoy sucking and/or drinking the blood too. Vanden Bergh and Kelly (1964) noted that the sucking or drinking of the blood from the wound is often an important part of the act but not necessarily essential.

Using the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), Dr Joel Milner, Dr Cynthia Dopke, and Dr Julie Crouch (2008) argue that if the individual’s vampirism causes pain and suffering in their victims it should be classed as a sexually sadistic paraphilia. However, if the victim does not suffer in any way, the vampirism should be classed as a paraphilia not otherwise specified (P-NOS). Milner and colleagues argue this approach is consistent with other P-NOS classifications involving other body fluids/substances (other than blood) such as urophilia (urine) and coprophilia (faeces).

Any discussion of vampirism wouldn’t be complete without at least a mention of Renfield’s Syndrome (RS) although it has yet to be included in the DSM. Renfield was a fictional mental patient in Bram Stoker’s novel Dracula (1887) who ate living things (flies, spiders, birds) believing that this would bring him greater ‘life force’ powers. The RS disorder, named in 1992 by clinical psychologist Dr Richard Noll (DeSales University, Pennsylvania, USA), is a rare psychiatric compulsion (not necessarily sexual and often linked with schizophrenia) – in which sufferers feel compelled to drink blood. As with some of the papers written on vampirism as a sexual paraphilia, this has also been called ‘clinical vampirism’. Like the character Renfield, RS sufferers believe that they can obtain increased power or strength (i.e., the ‘life force’) through the imbibing of blood.

RS sufferers are predominantly male (although there are known female vampirists), and like many paraphilias, the disorder often originates from a childhood event in which the affected individual associates the sight or taste of blood with psychological and/or physical excitement. It is during adolescence that the attraction to blood can become sexual in nature. Clinical evidence suggests female RS sufferers are unlikely to assault others for blood, but male RS sufferers are potentially more dangerous. It has been noted that RS usually comprises three stages:

• Stage 1 – Autovampirism (autohemophagia): In the first stage, RS sufferers drink their own blood and often bite or cut themselves to do so (although some pay just pick at their own scabs).
• Stage 2 – Zoophagia: In the second stage, RS sufferers eat live animals and/or drink their blood. The sources animal blood may come from butchers and abbatoirs if they have no direct access.
• Stage 3 – True vampirism: In the final stage, RS sufferers drink blood from other human beings. The sources of blood may be stolen from blood banks or hospitals or may be direct from other people. In the most extreme cases, RS sufferers may commit violent crimes including murder to feed their craving.

In a 1981 issue of the Journal of Clinical Psychiatry, Dr M. Benezech and colleagues reported a case study of cannibalism and vampirism in a French paranoid and psychotic schizophrenic. After trying to kill a number of people (mainly neighbours) between 1969 (when he was aged 29 years) and 1978, he attempted a vampiric rape on a child in 1979. Although he was stopped he went on later that day to murder an elderly man and successfully ate large pieces of the victim’s thigh, and attempted to suck his blood. Here, the vampirism was seen as secondary to the schizophrenia. A similar type case report of a 21-year old eastern European schizophrenic vampirist was published in 1999 by Dr Brendan Kelly (St James Hospital Dublin, Ireland) and colleagues in the Irish Journal of Psychological Medicine. However, the patient didn’t attempt to suck blood from himself or others but instead frequented a hospital accident and emergency department in search of their supply of blood for transfusion.

In a 1989 issue of the Journal of the Royal Society of Medicine, Dr A. Halevy and his colleagues reported the case of a 21-year old man (who had been in prison since he was 16 years old) who had anaemia and gastrointestinal bleeding as a result of self-inflicted injuries and blood ingestion on multiple occasions (for instance, one incident involved him cutting his arm with a razor blade, draining the blood into a glass, and then drinking it). He was classed by the authors as an ‘autovampirist’ in Prins’ typology although the authors were unable to determine if there was any sexual motivation involved.

In one of the few papers to examine more than one case study, Dr R.E. Hemphill and Dr. T. Zabow (1983, at the University of Cape Town) examined four vampirists in depth, including John Haigh (the English ‘acid-bath murderer’ who killed six people during the 1940s and drunk the blood of his victims), along with reference to other criminal vampirists. Hemphill and Zabow noted that since childhood all four cases had cut themselves, and that to relieve a craving they had drank their own, and others’ (human and/or animal) blood. All four cases were said to be intelligent with no mental instability or psychopathology in any of their family histories.

Most recently Dr K Gubb and his colleagues at the Tara Hospital Johannesburg (South Africa) published a case study of a 25-year old African man suffering from ‘psychic vampirism’ in the South African Psychiatry Review. In this paper, they argued that this particular type of clinical vampirism had never been reported in the literature before. The man was brought in for psychiatric treatment by his mother after he had become withdrawn, stopped socializing, was undressing in public, and started talking to himself. He claimed to hear the voice of ‘Sasha’, a “flame vampire from the scriptures of Geeta”. The man himself beleived he was “Vasever – lord of the vampires”. He claimed to have survived by hunting as a vampire by hurting more than 1000 humans “zooming in and out of them” (rather than biting them). Schizophrenia was diagnosed. The authors claimed that the vampirism was only of academic interest “because of its relative scarcity” but did not influence the diagnosis or treatment in any particular way.

They concluded that vampirism may be representative of some pathology other than schizophrenia (or simply represent an alternative belief system). Unlike other vampirism cases in the clinical literature, there was an absence of a fully developed psychopathic personality, along with a complete absence of sexual and gender identity disorders. This, they speculated, “may have protected the man from developing the homicidal, cannibalistic, libidinal and sexual features of vampirism seen in the other cases”.

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

Further reading

Benezech, M., Bourgeois, M., Boukhabza, D. & Yesavage, J. (1981). Cannibalism and vampirism in paranoid schizophrenia. Journal of Clinical Psychiatry, 42(7), 290.

Gubb, K., Segal, J., Khota1, A, Dicks, A. (2006). Clinical Vampirism: a review and illustrative case report. South African Psychiatry Review, 9, 163-168.

Halevy, A., Levi, Y., Ahnaker, A. & Orda, R. (1989). Auto-vampirism: An unusual cause of anaemia. Journal of the Royal Society of Medicine, 82, 630-631.

Hemphill R.E. & Zabow T. (1983) Clinical vampirism. A presentation of 3 cases and a re-evaluation of Haigh, the ‘acid-bath murderer’. South African Medical Journal, 63(8), 278-81.

Kelly, B.D., Abood, Z. & Shanley, D. (1999). Vampirism and schizophrenia. Irish Journal of Psychological Medicine, 16, 114-117.

Jaffe, P., & DiCataldo, F. (1994). Clinical vampirism: Blending myth and reality. Bulletin of the American Academy of Psychiatry and the Law, 22, 533-544.

Miller, T.W., Veltkamp, L.J., Kraus, R.F., Lane T. & Heister, T. (1999). An adolescent vampire cult in rural America: clinical issues and case study. Child Psychiatry and Human Development 29, 209-19.

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

Noll, R. (1992). Vampires, Werewolves and Demons: Twentieth Century Reports in the Psychiatric Literature. New York: Brunner/Mazel.

Prins, H. (1985). Vampirism: A clinical condition. British Journal of Psychiatry, 146, 666-668.

Vanden Bergh, R. L., & Kelly, J. F. (1964). Vampirism: A review with new observations. Archives of General Psychiatry, 11, 543-547.

Wilson N. (2000) A psychoanalytic contribution to psychic vampirism: a case vignette. American Journal of Psychoanalysis, 60, 177-86.

Yates, P.M., Hucker, S.J. & Kingston, W.A. (2008). Sexual sadism: Psychopathology and theory. In Laws, D.R. & O’Donohue, W.T. (Eds.), Sexual Deviance: Theory, Assessment and Treatment. pp.213-230. New York: Guildford Press.

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.

Spare fib: Should pathological lying be considered a mental disorder?

In a previous blog on weird addictions, compulsions and obsessions, I briefly looked at pathological lying. Writings relating to pathological lying first appeared in the psychiatric literature over 100 years ago and have been given names such as ‘pseudologia fantastica’ and ‘mythomania’ and often used interchangeably. There is some consensus that Dr. Anton Delbruck, a German physician was the first person to describe the concept of pathological lying in 1891 after publishing an account of five of his patients. Despite the long history of research, pathological lying is not included in either the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) or the World Health Organization’s International Classification of Diseases (ICD-10). The only mention of pathological lying in the DSM-IV is in association with Factitious Disorder (discussed below), However, many psychologists and psychiatrists claim that it is a distinct psychiatric disorder as highlighted in the many papers that have been published on the topic over the last two decades.

At a very simplistic level, pathological lying refers to a person that incessantly tells lies. However, Dr Charles Dike and his colleagues at Yale University define it as “falsification entirely disproportionate to any discernible end in view, may be extensive and very complicated, and may manifest over a period of years or even a lifetime, in the absence of definite insanity, feeble-mindedness or epilepsy”. However, there are other psychiatric conditions (such as people with Manipulative Personality) that may also engage in pathological lying as part of a wider set of behaviours and symptoms. In fact, there is a lot of debate as to whether the behaviour is really a discrete and unique entity or whether it typically manifests itself as an adjunct to other recognized psychological and/or psychiatric conditions. Dr Dike and colleagues note that:

“Pathological liars can believe their lies to the extent that, at least to others, the belief may appear to be delusional; they generally have sound judgment in other matters; it is questionable whether pathological lying is always a conscious act and whether pathological liars always have control over their lies; an external reason for lying (such as financial gain) often appears absent and the internal or psychological purpose for lying is often unclear; the lies in pathological lying are often unplanned and rather impulsive; the pathological liar may become a prisoner of his or her lies; the desired personality of the pathological liar may overwhelm the actual one; pathological lying may sometimes be associated with criminal behavior; the pathological liar may acknowledge, at least in part, the falseness of the tales when energetically challenged; and, in pathological lying, telling lies may often seem to be an end in itself. However, it is evident that no single descriptive tableau of a pathological liar settles all the nosological and etiological questions raised by the phenomenon of pathological lying” (p.344)

Dike and colleagues then went on to list a wide range of psychiatric conditions that have been associated pathological lying in an attempt to contextualize how the lying behaviour is manifested within these known conditions. The list of psychological and psychiatric conditions included: (i) Malingering, (ii) Confabulation, (iii) Ganser’s Syndrome, (iv) Factitious Disorder, (v) Borderline Personality Disorder, (vi) Antisocial Personality Disorder, (vii) Histrionic Personality Disorders. Arguably it is these last three disorders with which pathological lying is most associated with. The following briefly describes the symptoms and context of each of these conditions as outlined by Dr Dike and his colleagues:

• Malingering: This is deliberate lying where the person grossly exaggerates or totally lies about physical and/or psychological symptoms. Unlike ‘archetypal’ pathological liars, malingerers are typically motivated to tell lies for a specific purpose such as to obtain financial compensation, to avoid working, to avoid military service, to avoid criminal prosecution, etc.
• Confabulation: This is where people tell lies incessantly as a way of covering up memory lapses caused by specific memory loss conditions (e.g., organically derived amnesia). In ‘archetypal’ pathological liars, the condition is psychological (rather than organic) in origin.
• Ganser’s Syndrome (GS): GS is a rare dissociative disorder (only 101 recorded cases ever) characterized by affected people giving nonsensical answers to questions (and goes under many other names including ‘nonsense syndrome’ and ‘balderdash syndrome’). Unlike the elaborate and sometimes fantastical stories told by ‘archetypal’ pathological liars, the lies told by those with GS are very simplistic and approximate.
• Factitious Disorder (FD): FD is the deliberate use of lies and/or exaggerations concerning psychological and/or physical symptoms solely for the purpose of assuming the role of a sick person (formerly known as Munchausen’s Syndrome). In contrast, the ‘archetypal’ pathological liar doesn’t want to appear sick to other people.
• Borderline Personality Disorder (BPD): BPD is the condition where people have long-term patterns of unstable and/or turbulent emotions. Pathological lying and being deceitful are core characteristics of BPD and lies are typically told for personal profit or pleasure. Although. BPD patients typically have contradictory views about themselves and lack a consistent self-identity. A lack of impulse control may facilitate the distortions and lies told.
• Antisocial Personality Disorder (APD): APD is the condition in which the sufferer has a long-term pattern of manipulating, exploiting, or violating the rights of others (and is often criminal). Those with APD often lie repeatedly and consistently for personal satisfaction alone. Although those with APD are often pathological liars, ‘archetypal’ pathological liars rarely have disordered antisocial personalities.
• Histrionic Personality Disorder (HPD): Those with HPD act in a highly emotional and dramatic way to draw attention to themselves. They often lie as a way to enhance and/or facilitate their dramatic and attention-seeking behaviour. In contrast, ‘archetypal’ pathological liars do not constantly seek attention.

Based on the list above, it is evident that the symptom of pathological lying can occur in some mental disorders (e.g., FD, BPD) and could be called secondary pathological lying. However, it is much less clear whether it can occur independently of a known psychiatric disorder and be seen as primary pathological lying. Unlike other the other forms of lying outlined above, Dr Dike says pathological lying appears to be unplanned and impulsive. Despite all the speculation, there is still relatively little known although it’s thought to affect men and women equally with an onset in late adolescence. There are no reliable prevalence figures although one study estimated that one in a 1000 repeat juvenile offenders suffered from it.

On a biological and neurological level, a paper published in the Journal of Neuropsychiatry and Clinical Neurosciences reported the case of a pathological liar who was given a brain scan. Results showed that his condition was associated with right hemithalamic dysfunction. This supported the hypothesized roles of the thalamus and associated brain regions in the modulation of behavior and cognition.

A study published in the British Journal of Psychiatry reported differences in brain structure between pathological liars and control groups. Pathological liars showed a relatively widespread increase in white matter (approximately one-quarter to one-third more than controls) and the authors suggested that this increase may predispose some individuals to pathological lying.

Those working in the mental health system need to pay attention to pathological lying so that they can inform legal practitioners about whether pathological liars should be held responsible for their behaviour. Whether pathological liars are aware of the lies they tell has major implications for forensic psychiatry practice. Dr Dike says it could help determine how a court deals with pathological liars who provide false testimony while under oath.

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

Further reading

Delbruck, A (1891). Die pathologische Luge und die psychisch abnormen Schwindler: Eine Untersuchung uber den allmahlichen Uebergang eines normalen psychologischen Vorgangs in ein pathologisches Symptom, fur Aerzte und Juristen. Stuttgart, 1891, p 131.

Dike, C.C., Baranoski, M. & Griffith, E.E.H. (2005). Pathological lying Revisited. Journal of the American Academy of Psychiatry and Law 33, 342-349.

Healy W, Healy MT: Pathological Lying, Accusation, and Swindling. Boston: Little, Brown, 1926

King, B.H. & Ford, C.V. (1988). Pseudologia fantastica. Acta Psychiatrica Scandinavica, 77, 1-6.

Miller, P., Bramble, D., & Buxton, N. (1997). Case study: Ganser syndrome in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 112-115.

Modell, J.G., Mountz, J.M. & Ford, C.V. (1992). Pathological lying associated with thalamic dysfunction demonstrated by [99mTc]HMPAO SPECT. Journal of Neuropsychiatry and Clinical Neurosciences, 4, 442-446.

Yang, Y., Raine, A. Narr, K.L., Lencz, T., LaCasse, L., Colletti, P. & Toga, A.W. (2007). Localisation of increased prefrontal white matter in pathological liars. British Journal of Psychiatry, 190, 174-175.

Obscene and heard: A brief overview of telephone scatophilia

Telephone scatophilia (sometimes referred to as telephone scatologia and telephonicophilia) is a paraphilia that comprises overt or covert repetitive telephone calls with sexual and/or obscene content to an unsuspecting victim. The behaviour is also known to have a high association with other paraphilic disorders such as voyeurism and exhibitionism. The sexologist Professor John Money defined it as “deception and ruse in luring or threatening a telephone respondent, known or unknown, into listening to, and making personally explicit conversation of a sexual nature”. It is also worth noting as with some other paraphilias (e.g., such as exhibitionism, voyeurism), it is not the act itself that is deviant, but that it involves an interpersonal transgression involving a non-consenting victim.

At present, telephone scatophilia is listed as a “paraphilia not otherwise specified” in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV). Paraphilia listed in the ‘not otherwise specified’ category are said to occur much less frequently than the paraphilias that are individually listed, but it has been noted that telephone scatalophilia occurs on a much wider scale and magnitude than other paraphilias (e.g., necrophilia, zoophilia, klismaphilia) in this category. There are certainly surveys suggesting that relatively large numbers of women have received obscene telephone calls although it is theoretically possible for just one telephone scatophiliac to make hundreds (if not thousands) of telephone calls to different women. Almost all telephone scatophiliacs are male.

The prevalence rate of telephone scatophilia is unknown. One Canadian study reported that 6% of male students and 14% of paid male volunteers admitted to having made obscene phone calls. However, most research relies on case studies or surveys of paraphiliacs. For instance, in a study of 561 non-incarcerated paraphiliacs, Dr Gene Abel and colleagues’ reported that 19 men in the sample (3.3%) said they engaged in telephone scatologia. In a different study of 443 non-incarcerated paraphiliacs, In a study led by Dr John Bradford (Royal Ottawa Hospital, Canada), the authors reported that 37 men in the sample (8.3%) engaged in telephone scatalogia. Dr Marilyn Price and colleagues at the Harvard Medical School (USA) examined an outpatient sample of 206 men with paraphilias and paraphilia-related disorders and reported that 20 men in their sample (9.7%) had a lifetime diagnosis of telephone scatolophilia. This study reported that there was a significant comorbidity between telephone scatologia and compulsive masturbation, voyeurism, telephone sex dependence, and exhibitionism. Compared to other paraphiliacs, telephone scatolophiliacs had a greater number of lifetime paraphilias. Similar findings have also been reported in other studies. Professor Ord Matek (formerly of the University of Illinois, Chicago) suggests that the methods associated with both telephone scatophilia and paraphilias such as exhibitionism demonstrate the person’s attempts to express aggression, to exhibit power and control, and to gain recognition. However, unlike exhibitionists, telephone scatophiliacs usually want complete anonymity.

In 1975, Dr B.T. Mead developed an initial typology of obscene callers comprising three types:

• Type 1: These comprise telephone callers who immediately swear and/or make obscene propositions, and are typically adolescents.
• Type 2: These comprise telephone callers described as “ingratiating seducers” that use a more approach (saying they have mutual friends) before becoming more offensive.
• Type 3: These comprise telephone callers described as “tricksters” that use a ruse (e.g., pretending they are conducting a survey) in order to discuss personal matters. This eventually leads to obscene and sexual suggestions.

Professor Ord Matek claims there is a fourth type of obscene telephone caller. These are men who ring telephone crisis lines in order to request help from female volunteers, talks about sexual material, and masturbates while talking to the female on the other end of the telephone. Professor Matek also reported the most common features of obscene telephone callers were low self-esteem and anger toward women. Other associations reported were brain damage, mental retardation, intoxication and psychosis.

There are a number of theories as to how telephone scatophilia develops. Kurt Freund, the late Czech-Canadian sexologist wrote numerous papers claiming that behaviours such as telephone scatophilia are caused by “courtship disorders”. According to Freund, normal courtship comprises four phases: (i) location of a partner, (ii) pre-tactile interactions, (iii) tactile interactions, and (iv) genital union. Freund also proposed that obscene telephone calling is a disturbance of the second phase of the courtship disorder. Similarly, Professor John Money proposed the ‘‘lovemap’’ theory suggesting that paraphiliac behaviour occurs when an abnormal lovemap develops which interferes with the ability to participate in loving sexual intercourse. In this model, telephone scatologia, is classified as an allurement paraphilia involving the preparatory or courtship phase prior to genital intercourse. Although these models describe many cases of telephone scatophilia, there is some empirical evidence that some obscene telephone callers have normal courtship behaviour.

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

Further reading

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

Bradford, J.M.W., Boulet, J. & Pawlak, A. (1992). The paraphilias: A multiplicity of deviant behaviors. Canadian Journal of Psychiatry, 37, 104-108.

Dalby, J.T. (1988). Is telephone scatalogia a variant of exhibitionism? International Journal of Offender Therapy and Comparative Criminology 32, 45-50.

Kafka, M.P. (2010). The DSM Diagnostic Criteria for Paraphilia Not Otherwise Specified. Archives of Sexual Behavior, 39, 373-376.

Kafka, M. P., & Hennen, J. (1999). The paraphilia-related disorders: An empirical investigation of nonparaphilic hypersexuality disorders in 206 outpatient males. Journal of Sex and Marital Therapy, 25, 305-319.

Krueger, R.B., & Kaplan, M.S. (2000). The nonviolent serial offender: Exhibitionism, frotteurism, and telephone scatalogia. In L.B. Schlesinger (Ed.), Serial offenders: Current thought, recent findings (pp. 103–118). Boca Raton, FL: CRC Press.

Kaur, A.A. & Pankaj, G. (2009). Telephone scatologia: An aural assault. Journal of Punjab Academy of Forensic Medicine and Toxicology, 9(2), 87-91.

Matek, O. (1988). Obscene phone callers. Journal of Social Work and Human Sexuality, 7, 113–130.

Mead, B.T. (1975). Coping with obscene phone calls. Medical Aspects of Human Sexuality, 9, 127-128.

Money, J. (1986). Lovemaps: Clinical concepts of sexual/erotic health and pathology, paraphilia, and gender transposition in childhood, adolescence, and maturity. New York: Irvington.

Price, M., Kafka, M., Commons, M. L., Gutheil, T. G., & Simpson, W. (2002). Telephone scatologia: Comorbidity with other paraphilias and paraphilia-related disorders. International Journal of Law and Psychiatry, 25, 37-49.