Category Archives: Culture Bound Syndromes

Choking aside: Another look at self-asphyxial risk-taking behaviour in adolescence

In a previous blog I examined the ‘choking game’ (also known by dozens of names including the ‘fainting game’ and ‘suffocation roulette’). This was a game that I played a couple of times as an adolescent (although we called it ‘Headrush’). This was a game where I would have my breathing temporarily stopped by someone holding onto my chest after a deep expiration and hyperventilation (so that I could not breathe). It induced feelings of light-headedness and dizziness followed by temporary unconsciousness (usually lasting 10 to 15 seconds).

This activity that I engaged in as a teenager is an example of self-asphyxial risk-taking behaviour (SARTB). It also appears that what I did when I was an adolescent was a form of ‘self-induced hypocapnia’ (i.e., a state of reduced carbon dioxide in the blood). It has also been reported that these ‘games’ can be played alone and typically involve self-strangulation, or sometimes with others, and where like my own experiences, the cutting off of the oxygen supply was carried out by somebody else.

Reports of SARTB date back to the early 1950s in the medical literature (for instance, Dr. P. Howard and his colleagues reported a case in a 1951 issue of the British Medical Journal). SARTB has been defined by R.L. Toblin and colleagues in a 2008 issue of the Journal of Safety Research as self-strangulation or strangulation by another person with the hands or a noose to achieve a brief euphoric state caused by cerebral hypoxia. As with autoerotic asphyxiation (i.e., suffocation as a way of enhancing sexual arousal), the aim of SARTB is to intentionally cut off the oxygen supply to the brain to experience a feeling of euphoria (the only difference being that in children’s games, it is not done for a sexual reason).

How prevalent the activity is debatable as most of the academically published studies are case reports (usually when a problem – and in some cases, death – has occurred). However, a comprehensive systematic review of SARTB was recently published by Busse et al (2015). They attempted to assess the prevalence of engagement in SARTB and associated morbidity and mortality in children and adolescents (and up to early adulthood). Busse and colleagues examined every survey and case study that had been published on SARTB, and more specifically examining the behaviour among those aged 
0–20 years (excluding any study where the motive was autoerotic, suicidal or self-harm). They reported that 36 studies had examined child and adolescent SARTB in 10 different countries (North America and France being the most common, but also reports in the UK).

Risk factors for SARTB were hard to assess because most of the studies examining such risks did not control for other confounding variables. However, five of the studies reported an association between SARTB and a number of other risky behaviours including substance misuse, risky sexual behaviours, poor mental health, poor dietary behaviours, and engagement in risky sports. The review also reported that there did not seem to be any association between SARTB and engagement in physical activity, and experiencing accidents, and/or hospital admissions. It was also noted that a number of other behaviours increased the likelihood of engaging in SARTB including experiences of violence, being more impulsive, having a thrill-seeking personality, and having lower school achievement. However, only six of the 36 studies they reviewed reported the potential for SARTB to be associated with other risky behaviours. No consistent findings were found between SARTB and gender, age and other demographic factors (such as socio-economic status).

Examining the studies as a whole, Busse and colleagues reported that awareness of SARTB ranged from 36% to 91%, and that the median lifetime prevalence of engagement in SARTB was 7.4% (however, these were studies that used convenience sampling, therefore none of the studies were necessarily representative). In the SARTB literature, a total of 99 fatal cases were reported (and of the 24 detailed case reports, most of the deaths occurred when individuals were engaged in SARTB alone and used some type of ligature).

In a different analysis in the Journal of Safety Research, Dr. R.L. Toblin and colleagues used US news media reports to estimate the incidence of deaths from SARTB. Their report identified 82 probable SARTB deaths among youths aged 6-19 years during 1995 and 2007. Of these 82 cases, 71 (86.6%) were male, and the mean age of death was just over 13 years of age. The study also noted that deaths were recorded in 31 US states and were not clustered by location, season or day of week. Busse and colleagues assert the importance of education and prevention and more specifically note:

“As it has been suggested that knowledge and identification of symptoms and signs of engagement in [SARTB] could have possibly enabled early identification and possible prevention of fatal cases, we believe that clinicians, paediatricians, health professionals and teachers should receive education on the symptoms and signs of [SARTB]. The need to educate health professionals has been highlighted as awareness of [SARTB] will enable these individuals to identify symptoms and signs and to act as educators to young people and their parents…We further recommend that more research is carried out together with young people to develop appropriate education material. In line with recommendations from others, we further recommend removing existing videos about [SARTB] from the internet and ensuring that preventative website rather than promotional websites appear first on internet searches” (p.8).

This brief examination of the literature suggests that a significant minority of adolescents have engaged in SARTB and that in extreme cases it may lead to death. Despite being known about for over 60 years, the data concerning SARTB are still limited and relatively little is known about the associated risk factors. However, SARTB certainly appears to be an activity that parents and teachers should be made more aware of even if the prevalence of such activity among children and adolescents is low.

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

Further reading

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

Busse, H., Harrop, T., Gunnell, D. & Kipping, R. (2015). Prevalence and associated harm of engagement in self-asphyxial behaviours (‘choking game’)
in young people: A systematic review. Archives of Disease in Childhood, doi:10.1136/archdischild-2015-308187.

Drake, J.A., Price, J.H., Kolm-Valdivia, N. & Wielinski, M. (2010). Association of adolescent choking game activity with selected risk behaviors. Academic Pediatrics, 10, 410-416.

Egge, M.K., Berkowitz, C.D., Toms, C. & Sathyavagiswaran, L. (2010). The choking game: A cause of unintentional strangulation. Pediatric Emergency Care, 26, 206-208.

Griffiths, M.D. (2015). A brief review of self-asphyxial risk-taking behaviour in adolescents. Education and Health, 33, 59-61.

Howard, P., Leathart, G. L., Dornhorst, A.C., & Sharpey-Schafer, E.P. (1951). The mess trick and the fainting lark. British Medical Journal, 2, 382-384.

MacNab, A.J., Deevska, M., Gagnon, F., Cannon, W.G. & Andrew, T (2009). Asphyxial games or “the choking game”: A potentially fatal risk behavior. Injury Prevention, 14, 45-49.

Shlamovitz, G.Z., Assia, A., Ben-Sira, L. & Rachmel, A. (2003). “Suffocation roulette”: A case of recurrent syncope in an adolescent boy. Annals of Emergency Medicine, 41, 223-226.

Toblin, R.L., Paulozzi, L.J., Gilchrist, J. & Russell, P.J. (2008). Unintentional strangulation deaths from the “choking game” among youths aged 6-19 years -United States, 1995-2007. Journal of Safety Research, 39, 445-448.

Urkin, J. & Merrick, J. (2006). The choking game or suffocation roulette in adolescence (editorial). International Journal of Adolescent Medicine and Health, 18, 207-208.

Ghost modernism: Should parents worry about their children playing supernatural games?

(Note: A version of this article was first published in The Independent)

Supernatural games have been played for decades by children and adolescents all around the world. The most popular games – often played on Halloween – include holding séances and playing on a Ouija board to summon up the spirit world, playing hide-and-seek in the pitch black dark, ‘Bloody Mary’ (staring into a mirror, alone in the dark and saying “Bloody Mary” three times to summon up a ghoulish woman), and ‘Candy Man’ (again staring into a mirror and saying “Candy Man” five times to summon up the ghost of a black slave covered in blood and where thousands of bees emerge from his mouth).

The latest game that has done the rounds is the ‘Charlie Charlie Challenge’ (also known as ‘Charlie Pencil’ and ‘The Pencil Game’) and viewed by some as a rudimentary Ouija board. Both of my younger children saw the game on social media although neither has played it. The game is very simple to play and like ‘Bloody Mary’ and ‘Candy Man’ is played to invoke a spirit (this time a dead Mexican called Charlie). The game simply involves placing two pencils on a piece of blank paper in the shape of the cross with the words ‘yes’ and ‘no’ written on either side of the pencils. Players say the phrase “Charlie, Charlie can we play?” in order to connect with the demon. Players then ask questions of the demon and the pencils move to indicate his answer.


There has been no academic research into the playing of supernatural games by children but there is anecdotal evidence that such games are popular. For instance, according to one news report in the Daily Mail, the sales of Ouija boards increased by 300% in December 2014 and are marketed for children and adolescents as they are sold in places like Toys R Us.

The obvious questions to ask is why our children like to play these scary games in the first place and is there is any harm that children can experience from playing such games? Although there has been no research on the playing of supernatural games there has been a little research on why we like watching scary supernatural films. Psychological research has shown that when it comes to the supernatural the three main reasons we watch supernatural horror films are for tension (generated by the suspense, mystery, terror, etc.), relevance (that may relate to personal relevance, cultural meaningfulness, the fear of death, etc.), and (somewhat paradoxically given the second reason) unrealism (i.e., being so far removed from our day-to-day existence). However, the research that has been carried out tends to be on student populations rather than younger children and adolescents. The reasons why school-aged children may want to watch or engage in supernatural practices are likely to be far more mundane such as teenage bravado to try and impress others around them or as a ‘rites of passage’ activity (i.e., engaging in an activity that is normally done by adults and makes the child feel more grown-up).

Although I don’t subscribe to the theories forwarded by the psychoanalyst Dr. Carl Jung, he believed the liking for supernatural horror films tapped into our ‘primordial archetypes’ buried deep in our collective subconscious. However, as with almost all psychoanalytic theorizing, such notions are hard to scientifically test. Another psychoanalytic theory – although arguably dating back to Aristotle – is the notion of catharsis (i.e., that we watch and engage in frightening activities as a way of purging negative emotions and/or as a way to relieve pent-up frustrations).

When it comes to whether playing supernatural games are harmful for children, there are two schools of thought but there is no empirical evidence to support either position. There are those that emphatically claim that the playing of such games is not a dangerous activity. Opposed to this view are those (often religious) people that claim that using Ouija boards and playing supernatural games are dangerous. For instance, Father Stephen McCarthy, a Catholic priest claimed the ‘Charlie Charlie Challenge’ was a demonic activity. In an open letter to students he said:

“There is a dangerous game going around on social media which openly encourages impressionable young people to summon demons. I want to remind you all there is no such thing as ‘innocently playing with demons’. Please be sure to NOT participate and encourage others to avoid participation as well. The problem with opening yourself up to demonic activity is that it opens a window of possibilities which is not easily closed.”

As both a psychologist and a father of three adolescents, I have yet to see any evidence that the playing of such games does any psychological harm although it’s not an activity that I would actively encourage either. As a teenager and as a university student I playfully engaged in séances and at one party used a Ouija board and it never did me any harm. Some may even argue that such activities are ‘character building’. However, there may be children and adolescents of a more sensitive disposition where such games might have a more long-lasting negative detrimental effect. The truth of the matter is that we simply have no idea about what effects of playing games like the ‘Charlie Charlie Challenge’ have on the psyche or behaviour.

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

Further reading

Hess, J.P. (2010). The psychology of scary movies. Filmmaker IQ. Located at:

Hoekstra, S. J., Harris, R. J., & Helmick, A. L. (1999). Autobiographical memories about the experience of seeing frightening movies in childhood. Media Psychology, 1, 117-140.

Johnston, D.D. (1995). Adolescents’ motivations for viewing graphic horror. Human Communication Research, 21(4), 522-552.

O’Brien, L. (2013). The curious appeal of horror movies: Why do we like to feel scared? IGN, September 9. Located at:

Blood discussed: A brief look at haematophagia

Haematophagia usually refers to the practice of animals feeding on the blood of another species. However, the term has also been applied to humans that consume blood (something that I have referred to in previous blogs on clinical vampirism and menophilia). Most writings on human haematophagia usually refer to the practice in some sexual and/or vampiric capacity (e.g., some individuals in China and Vietnam believe certain types of snake blood are aphrodisiacs and are drunk with rice wine) but haematophagia can also occur for other reasons.

While I working was in Spain, I was taken to one of the best Castilian restaurants, and as part of the starter I was served morcilla sausage. Morcilla sausage is basically a Spanish version of black pudding (aka ‘blood pudding’) and made from pig’s blood. I absolutely loved it. It did make me wonder what other ‘blood’ foods I might enjoy. I did a bit of research into the making of blood sausages and found out that variations of this dish exist in cultures all over the world (e.g., Europe, Asia, and the Americas), and that all kinds of different animals’ blood can be used (including pigs, sheep, cattle, goats, and ducks). According to the Wikipedia entry on human haematophagia:

“Drinking blood and manufacturing foodstuffs and delicacies with animal blood is also a feeding behavior in many societies. Cow blood mixed with milk, for example, is a mainstay food of the African Massai. Some sources say that Mongols would drink blood from one of their horses if it became a necessity. Black pudding is eaten in many places around the world. Some societies, such as the Moche, had ritual hematophagy, as well as the Scythians, a nomadic people of Russia, who had the habit of drinking the blood of the first enemy they would kill in battle…Psychiatric cases of patients performing hematophagy also exist. Sucking or licking one’s own blood from a wound is also a behavior commonly seen in humans, and in small enough quantities is not considered taboo. Finally, human vampirism has been a persistent object of literary and cultural attention”

There a numerous YouTube videos of the African Massai (in Tanzania) drinking blood directly from the necks of live cattle (such as here and here). Cattle blood drinking typically occurs after special celebrations (such as births, ritual circumcisions, etc.), but the special occasions are not compulsory for blood drinking to occur. The cattle are never killed and the cuts made to drink blood from appear to heal quickly. One report on the Environmental Graffiti website described the practice:

“Half a dozen Maasai warriors wrestle with the struggling cow. Another waits with his bow drawn, arrow at the ready. Finally, they have the straining animal in position. The warrior with the weapon shoots straight for the bovine’s jugular. Warm blood gushes into a waiting bucket, pumped out by the animal’s still-beating heart. The blood keeps flowing, almost filling the container, before the cow is released – its punctured neck sealed with a dab of cow dung. It will live to see another day. Its’ blood-donating job is done, at least for another month. The Maasai men who perform this blood-draining ritual do not intend to kill, or even harm, the animal. They merely want some of its nourishing crimson fluid to drink”.

Another Wikipedia entry focusing on blood as food notes that in addition to blood sausages, animal blood has also been used to thicken, colour, and/or flavour sauces and gravies, and for various types of blood soup (such as ‘czernina’ in Poland, ‘papas de sarrabulho’ in Portugal, and ‘svartsoppa’ made with goose blood in Sweden). Although blood is a taboo food in some cultures, in others it is perfectly acceptable – particularly in times when food has been scarce. Other cultures have other blood foods including blood pancakes (in Scandinavian and Baltic countries), blood tofu (China, Thailand, Vietnam), blood cake (Taiwan), blood potato dumplings (‘blodpalt’ made with reindeer blood in Sweden) and blood bread (‘paltbrod’ in Sweden). Additionally, Wikipedia noted that:

“Blood can also be used as a solid ingredient, either by allowing it to congeal before use, or by cooking it to accelerate the process. In Hungary when a pig is slaughtered in the morning the blood is fried with onions and is served for breakfast. In China, ‘blood tofu’ is most often made with pig’s or duck’s blood, although chicken’s or cow’s blood may also be used. The blood is allowed to congeal and simply cut into rectangular pieces and cooked. This dish is also known in Java as saren, made with chicken’s or pig’s blood. Blood tofu is found in curry mee as well as the Sichuan dish, maoxuewang. In Tibet, congealed yak’s blood is a traditional food”.

The Tanzanian Massai people are not the only culture to consume uncooked animal blood products. For instance, Inuits living in the Arctic Circle consume seal blood and believe it to have health and social benefits. According to a paper on consuming seal blood in a 1991 issue of Medical Anthropology Quarterly, seal blood is “seen as fortifying human blood by replacing depleted nutrients and rejuvenating the blood supply, [and] is considered a necessary part of the Inuit diet”. Another academic paper by Dr. Edmund Searles in a 2002 issue of the journal Food and Foodways reported that in relation to the drinking of seal blood: Inuit food generates a strong flow of blood, a condition considered to be healthy and indicative of a strong body”. Historically, there are accounts of Irish people bleeding cattle as a preventative measure against cattle diseases. The Wikipedia entry on blood as food claims that the Irish mixed the drawn blood with butter, herbs, oats or meal” to provide a “nutritious emergency food”.

During my research I also came across a story in The Atheist Times (with photographic evidence) of Hindus engaged in the practice of decapitating and drinking goat blood directly from its body (a blood sacrifice). The report claimed the practice was widely prevalent throughout India and Malaysia. These Hindus believe that the Hindu goddess Kali descends upon those drinking the goat’s blood.

Staying on the religious theme, there are (of course) many (arguably ‘mainstream’) simulated acts of haemotphagia – most notably in various religious ceremonies and rituals. The most obvious is in the transubstantiation of wine as the blood of Jesus Christ during Christian Eucharist (where religious followers believe they are drinking the blood of Christ). Various religions engage in such pseudo-haemotophagic practices including the Catholic Church, Eastern Orthodox, Oriental Orthodox, some Anglican, and Lutheran churches. (Other religions are the exact opposite and consider the drinking of blood taboo such as Jewish and Muslim cultures).

As this brief review demonstrates, non-sexual and non-vampiric human haematophagia and pseudo-haematophagia appear to be common and widespread in many cultures and countries. Academic research on the topic appears to be limited although it certainly warrants further investigation.

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

Further reading

Borré, K. (1991). Seal blood, Inuit blood, and diet: A biocultural model of physiology and cultural identity. Medical Anthropology Quarterly, 5, 48-62.

Davidson, A (2006). The Oxford Companion to Food. Oxford: Oxford University Press.

Searles, E. (2002). Food and the making of modern Inuit identities. Food and Foodways, 10(1-2), 55-78.

Wikipedia (2013). Blood as food. Located at:

Wikipedia (2013). Hematophagy. Located at:

Acting up: A brief look at the ‘Hollywood Phenomenon’ delusion

In a previous blog I briefly examined Delusional Misidentification Syndromes (DMSs). These are arguably some of the strangest mental and neurological syndromes that exist. All DMSs involve a belief by the affected individual that the identity of something (i.e., a person, place, object, etc.) has altered or changed in some way. There are many variants of DMS, and in most cases the delusion is monothematic (i.e., it only concerns one particular topic). The DMSs that are most written about are:

  • The Fregoli delusion (individuals who have the belief that more than one person that they have met is the same person in more than one disguise).
  • The Capgras delusion (individuals who have the belief that someone (typically a spouse or close relative) has been replaced by an identical-looking imposter.
  • Subjective doubles (aka Christodoulou syndrome) (individuals who have the belief that there are (one or more) doubles of themselves [i.e., doppelgangers] that carry out actions and behaviours independently and lead a life of their own.
  • Intermetamorphosis: (individuals who have the belief that people in their immediate vicinity change identities with each other but keep the same appearance.

According to Dr. K.W. De Pauw and Dr. T.K. Szulecka in a 1988 issue of the British Journal of Psychiatry, those with DMSs are “more likely to commit violent crimes against persons than those with chronic, undifferentiated psychoses”. In their paper, De Pauw and Szulecka reviewed the literature concerning violence associated with DMSs and reported four case studies of individuals that were “either perpetrators or victims of assaults as a consequence of the syndromes of Fragoli, Intermetamorphosis, Subjective Doubles and Capgras”. After this paper was published, Dr. A.P. Shubsachs and Dr. A. Young responded to the paper (also in the British Journal of Psychiatry) with a short account of two case studies with a variant of delusional misidentification environment”.

The two cases had a delusion that was described as the ‘Hollywood Phenomenon’ and comprised the belief “that the patient’s environment has been changed to a film or theatre set peopled by actors and in which the patient has a role to play”. (This also appears to be similar to the ‘Truman Show’ Delusion that I described in a previous blog and is “a novel delusion, primarily persecutory in form, in which the patient believes that he is being filmed, and that the films are being broadcast for the entertainment of others”).

Shubsachs and Young asserted that the ‘Hollywood Phenomenon’ (HP) was a symptom rather than a syndrome. They also reported that based on their tow case studies, HP can occur along with atypical Capgras phenomenon, and may result in violence, verbal hostility, and non co-operation. Here are the two case studies in the authors’ own words (taken verbatim from the British Journal of Psychiatry):

  • Case 1: “Mr. A, a 22-year-old single Australian man with a history of two admissions for bipolar affective disorder, left Australia in the early stages of a manic episode. On arrival in the UK his condition deteriorated, with elevated mood, decreased sleep, excess energy, and accelerated thoughts. He recognised that he was relapsing and consulted a GP, who arranged an urgent out-patient appointment. Before that appointment he became convinced he was ‘an actor and that everything that was going on was a film’ in which he was the main player. He stole a car which he deliberately crashed because ‘it was a stunt car and I was a stunt man who was supposed to crash it…it was rigged so I wouldn’t get hurt’. He was arrested and later assaulted the police surgeon with what he erroneously believed was a bottle of ‘harmless sugar glass’ causing severe injuries. Mr A. claimed that he, the surgeon, and the police were all play actors and that his actions would have ‘no real consequence’. Remanded in prison for psychiatric reports, he was intermittently violent in response to similar misidentifications until he became euthymic following medication. He was transferred Hospital Order, and on admission had insight into his previous delusions”.
  • Case 2: “Miss B. exhibited both a Capgras phenomenon and a ‘Hollywood phenomenon’. She was a single retired midwife in late middle age, living alone. She had had several admissions with a diagnosis of depressive psychosis or schizophrenia. On this occasion she was depressed with early morning wakening, psychomotor retardation, appetite and weight loss, and felt hopeless and worthless. She believed relatives were impostors and was verbally aggressive towards them. She believed that the hospital was a film set peopled by actors, the admitting doctor a film director, and that the purpose of the interview was to obtain a script for the film. While she struggled and was verbally hostile at attempts to detain her, there was no serious violence. She recovered fully after ECT”.

Shubsachs and Young claimed that the HP delusion was both uncommon and under-reported, and that both of the cases that they described involved “affective illness without organic impairment”. They then went on to claim that they didn’t think that the ‘Hollywood Phenomenon’ was “specific for affective disorders” (and asked if other psychiatrists reading their case studies could provide other examples). They concluded that the HP “differs from the superficially similar transient experience in derealisation in that it has a real, not an ‘as if’ quality, is enduring, and has all the features of a delusion including the tendency to be acted upon”.

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

Further reading

Christodoulou G.N. (1986). Delusional Misidentification Syndromes. Basel: Karger.

De Pauw, K. W., & Szulecka, T. K. (1988). Dangerous delusions. Violence and the misidentification syndromes. British Journal of Psychiatry, 152(1), 91-96.

Ellis, H.D., Luauté, J.P. & Retterstøl, N. (1994). Delusional misidentification syndromes. Psychopathology, 27(3-5), 117-120.

Enoch, M.D. & Trethowan, W. (1979). Uncommon Psychiatric Syndromes. Oxford: Butterworth-Heinemann; 1979.

Fusar-Poli, P., Howes, O., Valmaggia, L., & McGuire, P. (2008). ’’Truman’’ signs and vulnerability to psychosis. British Journal of Psychiatry, 193, 168.

Gold, J. & Gold, I. (2012). The “Truman Show” delusion: Psychosis in the global village. Cognitive Neuropsychiatry, 17, 455.

Shubsachs, A.P., & Young, A. (1988). Dangerous delusions: The ‘Hollywood phenomenon’. British Journal of Psychiatry, 152(5), 722-722.

Germanic street preachers: The psychology of Krautrock

Regular readers of my blog will be aware that I describe myself as a music obsessive with an eclectic taste ranging from Iggy Pop and Adam Ant through to the Velvet Underground and Throbbing Gristle. Another genre of music that I have more than a passing interest is that of ‘Krautrock’ (see my previous blog on Kraftwerk and their alleged addiction to cycling). Krautrock (as you can probably guess) is a somewhat derogatory term – believed to have been coined by the renowned music journalist Ian MacDonald – to describe a number of German bands that came to the fore in the British music scene in the early 1970s (most notably Amon Düül, Faust, Can, Kraftwerk, Neu!, Kluster, Cluster, Harmonia, Popol Vuh, Ash Ra Tempel, and Tangerine Dream).

Krautrock (as defined by the British media) has traditionally been viewed as electronic in nature (although many of the compositions in the late 1960s were far from electronica and utilized ‘found sounds’ from whatever was to hand) with an emphasis on improvisation and somewhat minimalistic arrangements. The Wikipedia entry on Krautrock also notes that:

“The term is a result of the English-speaking world’s reception of the music at the time and not a reference to any one particular scene, style, or movement, as many Krautrock artists were not familiar with one another…Largely divorced from the traditional blues and rock and roll influences of British and American rock music up to that time, the period contributed to the evolution of electronic music and ambient music as well as the birth of post-punt, alternative rock, and new-age music”.

Given my profession, it won’t surprise you to know that as much as I love music itself, I am also interested in the psychology of the musicians too. When it comes to Krautrock, I have argued for the best part of 20 years (to anyone that would listen) that the psychology of the archetypal Krautrocker in the late 1960s was likely to be influenced by being raised in post-second world war Germany. It was only over the holiday period that my thoughts were confirmed by the artists themselves (in interviews with journalists and musicologists).

More specifically, I read two excellent books on different aspects of ‘extreme music’ over the Christmas period – Future Days: Krautrock and the Building of Modern Germany (by David Stubbs), and Assimilate: A Critical History of Industrial Music (by S. Alexander Reed). Alongside this, I also watched the wonderful three-hour documentary DVD Kraftwerk and the Electronic Revolution, the BBC 4 documentary, Krautrock: The Rebirth of Germany, and the 2008 film The Baader Meinhof Complex (about the Red Army Faction, left-wing German militant group and based on the 1985 non-fiction book of the same name by Stefan Aust).

These books and films all made reference to the cultural, political, and psychological climate in post-war West Germany. There were a number of repeated themes that I couldn’t fail to notice. Firstly, many of the middle classes holding a lot of the important jobs (mayors, town leaders, judges, professors, teachers) were still Nazi sympathizers. Secondly, children born after 1945 were generally not told about their history by either their parents or their schoolteachers. Thirdly, in the late 1950s and early 1960s, teenagers said they experienced feelings of guilt but didn’t know what for. On the musical front, West Germany’s pre- and post-war musical legacy was “Schlager” music (described by music journalist Adam Sweeting as a genre unpleasantly redolent of the sentimental slop with which Josef Goebbels had saturated the Third Reich”). As Wikipedia notes that:

“Schlager music (German: Schlager, synonym of “hit-songs” or “hits”), also known in the United States as entertainer music or German hit mix, is a style of popular or electronic music…Typical schlager tracks are either sweet, highly sentimental ballads with a simple, catchy melody or light pop tunes. Lyrics typically center on love, relationships and feelings”.

By the late 1960s, many older teenagers and students were united in their politics (the most high profile touch point arguably being the student protests across Europe in 1968). They were also united in their dislike of schlager music except they didn’t really know they were united. Pockets of underground music sprouted up across a number of towns and cities across Germany. Key bands in the history of Krautrock were formed in Dusseldorf (Neu!, Kraftwerk), Cologne (Can), Berlin (Kluster, Tangerine Dream), Munich (Amon Düül), and Wumme (Faust). Bands playing in one city had no idea that bands were forming in other parts of Germany with similar ideological, political and psychological roots. More bizarre was that none of these bands – at least initially – had no following in Germany itself. Most fans of these bands were in the UK rather than their homeland. It was the British music press (NME, Sounds) and DJs (most notably John Peel) that were waving the German flag.

Arguably, the most overtly political of the emerging Krautrock bands was Munich’s Amon Düül. Their band members lived in a radical West German commune including the gang that formed the Red Army Faction (RAF) in 1970 (the so-called Baader-Meinhof Group (or Baader-Meinhof Gang including Andreas Baader, and Ulrike Meinhof). The members of Amon Düül quickly dissociated themselves from the RAF saying that their comrades were going too far in making their political presence known. In fact, the band members ended up falling out with themselves leading to different versions of the band with the second incarnation (Amon Düül 2) becoming the most revered.

Another important hotbed of anti-schlager musical development was the formation of the Zodiak Free Arts Lab (also known as the Zodiak Club) by experimental musician Conny Schnitzler in West Berlin. The Zodiak Club provided a hub where anyone could come and play whatever they wanted amongst like-minded people pushing the boundaries of music with whatever was at hand. Schnitzler himself was an early member of Tangerine Dream as well as the founding member of later Krautrock bands such as Kluster and Eruption. The other important figure in West Berlin’s burgeoning Krautrock scene was Hans-Joachim Roedelius who played with Schnitzler in Kluster but then went on to form Cluster with Deiter Moebius (another key player in the Krautrock movement) but without Schnitzler.

In relation to the psychology of Krautrock, Michael Rother (an early member of Kraftwerk, co-founder of Neu!, and later in ‘supergroup’ Harmonia) was interviewed by David Stubbs in his book Future Days. Rother had actually studied psychology and that as a German he strived for an alternative identity, and a new personality almost:

“Studies into psychology also assisted Rother in realizing that as a young man coming of age in Germany in the late 1960s, he could not be impervious to the cultural, social and political forces ranging at that time, all of which would have a profound impact on his musical identity. He rejected out of hand the burgeoning violence and ‘lunacy’ of terrorist movements such as the Baader-Meinhof group, whom he regarded as on the wrong road altogether. At the same time, the horrors of the Vietnam War acted as a jolting reminder of the need to wrench oneself away from Anglo-American hegemony, to create oneself as a personality anew”.

Rother’s perceptions and psychological insights appear to have been shared by many other individuals forming bands across West Germany in the late 1960s. The complete silence by parents and teachers towards children about the actions of Hitler and the Nazis (most notably the genocide of the Jewish people living in Germany) left post-war adolescents psychologically ill at ease about their national and cultural identities. They needed to create something unique, something identifiably German, and something they would feel proud of. The new music of Krautrock met such criteria. But was the music really that new? Some (including myself) would argue that much of the burgeoning music in Munich, Dusseldorf, Cologne and Berlin had its’ roots in ‘musique concrète’ (“concrete music”) and the work of Karlheinz Stockhausen.

Developed by French composer Pierre Schaeffer at the Studio d’Essai (“Experimental Studio”) of the French radio system, musique concrète is a form of electroacoustic music. It comprises an experimental technique of musical composition that uses recorded sounds as raw material to create a montage of sound (often referred to as ‘found sounds’ but can include recordings of voice and musical instruments). Musique concrète compositions don’t follow any conventional musical rules of melody, rhythm or harmony. Many musicologists view musique concrete as a precursor to electronica. Furthermore, many groups from Throbbing Gristle to Depeche Mode have sampled ‘found sounds’ in their musical output as well as many of the earlier pioneers in Krautrock.

The roots of Krautrock can also be traced back to one of Germany’s musical giants, Karlheinz Stockhausen. I’ve been aware of Stockhausen’s work through his influence on the Beatles (Stockhausen is one of the figures on their 1967 Sgt. Pepper’s Lonely Hearts Club Band LP cover). Although in the public’s mind it was John Lennon that was associated with the more avant-garde recordings by the Beatles (‘Revolution 9’ and ‘What’s The New Mary Jane’) and his first solo albums with second wife Yoko Ono (Two Virgins, Life With The Lions, and Wedding Album), it was actually Paul McCartney who first developed an interest in avant-garde composers such as Stockhausen. (In fact, prior to his relationship with Ono, Lennon was famously quoted as saying “Avant-garde is French for bullshit”). Evidence for McCartney’s interest in Stockhausen and the avant-garde is the still unreleased Beatles composition ‘The Carnival of Light’ recorded in January 1967 for The Million Volt Light and Sound Rave held at the Roundhouse Theatre).

Stockhausen is seen by many as one of the greatest musical innovators and visionaries of the twentieth century. His electronic compositions were way ahead of his time, and had a large influence on many more modern day recording artists including Frank Zappa, Pete Townsend (The Who), Roger Waters (Pink Floyd), and Björk. In relation to Krautrock, two members of Can (Irmin Schmidt and Holger Czukay) were actually tutored by Stockhausen at the Cologne Courses for New Music, and Kraftwerk claim they also studied under him.

In terms of Krautrock’s influence on modern music, it doesn’t matter whether it was genuinely new. It was genuinely (West) German and grew largely from individuals’ psychological and/or political reaction to their experiences of growing up in post-war Germany following the fall of Nazism. The content of the output may not have been psychologically-based, but the attitude and spirit in making such music arguably was. We are all products of our genetics and our environment, and post-war teenagers born after 1945 in Germany experienced a culture and an immediate history that most can never ever experience. The Krautrockers fighting (artistically, culturally and literally) against the ‘establishment’ in late 1960s brought about some of the greatest music ever produced, and I for one, am eternally grateful for the pleasure it has brought in my own life.

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

Further reading

Blaney, J. (2005). John Lennon: Listen to this Book. Guildford: Paper Jukebox, Biddles Ltd.

Buckley, D. (2012). Kraftwerk Publication. London: Omnibus.

Cope, J. (1996). Krautrocksampler (Second Edition). Head Heritage.

Reed, S.A. (2013). Assimilate: A Critical History of Industrial Music. New York: Oxford University Press.

Stubbs, D. (2014). Future Days: Krautrock and the Building of Modern Germany. London: Faber & Faber.

Wikipedia (2014). Krautrock. Located at:

Wikipedia (2014). Musique concrète. Located at:ète

Double trouble: Syndrome of subjective doubles‬

In a previous blog on Delusional Misidentification Syndromes, I briefly mentioned the rare syndrome of ‘subjective doubles’ (SSD). Also known as Christodoulou syndrome (after the Greek psychiatrist Dr. George Nikos Christodoulou who first wrote about the syndrome), SSD refers to individuals who have the belief that there are (one or more) doubles of themselves (i.e., doppelgangers) that carry out actions and behaviours independently and lead a life of their own but that have part or sometimes all of the SDD sufferer’s personality. If the sufferer believes that (some or all of) their personality has been transferred to their doppelganger, they may also experience depersonalization (i.e., a problem of self-awareness in which individuals feel they have little control over social situations and feel they are watching themselves act in a vague and dreamlike state. As with other DMSs, subjective doubles syndrome typically arises as a consequence of a mental disorder, brain injury (typically the right central hemisphere) or a neurological disorder. The Wikipedia entry on SSD cited the case of a man who became depersonalized after an operation and was convinced his brain had been placed into someone else’s head and then claimed he recognized the other person.

In the original paper on SSD in a 1978 issue of the American Journal of Psychiatry, Dr. Christodoulou described the case of a young 18-year-old woman who claimed that a female neighbour had (via an “elaborate transformation” involving “metapmophosis”) acquired all of her physical characteristics (“same face, same build, same clothes, same everything’) and become an identical double. To become her double, the female case study believed her doppelganger had used a mask, wig, and special makeup. Her female neighbour wasn’t the only doppelganger as the woman also claimed at least one other woman had become her doppelganger. In rare instances, there may be comorbidity with the Capgras delusion (another misidentification syndrome) and is then referred to ‘subjective Capgras syndrome’. In fact, there are a number of different sub-types of SDD. As the online Dictionary of Hallucinations notes:

A subdivision of the syndrome of subjective doubles yields a ‘Capgras type’ (characterized by the delusional conviction that unseen doubles are active in the affected individual’s environment), an ‘autoscopic type’ (in which doubles of the self are perceived, ‘projected’ onto other people or objects, as in pareidolia), and a ‘reverse type’ (in which the affected individual believes to be an impostor or to be about to be replaced by someone else). The syndrome of subjective doubles is associated with various psychiatric disorders (notably the group of so-called schizophrenia spectrum disorders) and neurological disorders (notably disorders of the right parieto-temporal lobe). Conceptually and phenomenologically, the syndrome of subjective doubles constitutes the counterpart of a syndrome called ‘mirrored self-misidentification’, in which the affected individual is unable to identify his or her mirror image as oneself”.

Although most sources cite Dr. Christodoulou’s paper in the American Journal of Psychiatry as the first recorded case of SSD, he actually published a paper a year earlier in a 1977 issue of Acta Psychiatrica Belgica on the treatment of the syndrome of doubles. In this paper, Christodoulou used biological methods to treat 20 psychiatric patients with SDD or the related syndromes (Frégoli, intermetamorphosis, Capgras) aged 17 to 67 years of age. His patients were treated with ECT, antidepressants, neuroleptics, and antiepileptics (in some cases given singly whereas others were in combination). It was reported that:

“Results show that (a) the syndrome of doubles responded to various biological treatment methods; (b) in depression, it responded to tricyclic antidepressants; (c) in schizophrenia or organic psychosis, it usually responded to neurolytics; (d) in schizophrenia, it had more chances of responding to trifluoperazine given alone or in association with other psychopharmacological drugs; and (e) in certain cases, combination of antipsychotic treatment with treatment of coexisting organic dysfunctions appeared to be important”.

In another 1978 paper (in the Journal of Nervous and Mental Disease), Dr. Christodoulou described the course and prognosis of 20 patients with the syndrome of doubles (including Capgras syndrome, Fregoli syndrome, intermetamorphosis syndrome, and SDD – and presumably the same cases reported in the 1977 paper). He reported that the onset of the syndromes occurred either synchronously or at a later stage than the onset of the associated psychosis. In seven of the 20 cases, the syndrome failed to remit. In the remaining 13 cases, remission occurred either synchronously with or later than the remission of the basic psychosis. In all cases where there was comorbid depression, the syndromes cleared shortly after the successful treatment of the depressive illness. It was also noted that relapse of the basic psychotic condition in the setting of which the syndrome had originally developed was usually accompanied by the syndrome reappearing. In one of his most recent papers (from a 2009 issue of Current Psychiatry Reports), Christodoulou and three of his colleagues noted that:

“The delusional misidentification syndromes [including SDD] are rare psychopathologic phenomena that occur primarily in the setting of schizophrenic illness, affective disorder, and organic illness. They are grouped together because they often co-occur and interchange, and their basic theme is the concept of the double. They are distinguished as hypoidentifications (Capgras’ syndrome) and hyperidentifications (the other three syndromes [including SDD]).,,[We] propose that the appearance of these syndromes must alert physicians to investigate the existence of possible organic contributions”.

Compared to other misidentification syndromes, SDD appears to be relatively rare and is often comorbid with other similar conditions. For instance, in a 1986 issue of the Journal of Clinical Psychiatry, Dr. A.B. Joseph described the case of a 30-year old white male who had SDD along with paranoid schizophrenia, Cotard’s syndrome, Capgras delusion, and palinopsia (visual perseveration). Joseph concluded that cerebral dysfunctions in the confluence of the parietal, temporal, and occipital regions of the brain appeared to account for the disorders. Similarly, a 1996 paper in the journal Australasian Psychiatry, Dr. S. Atwal and Dr. M. Khan reported an unusual case of Capgras syndrome coexisting with three related syndromes (Fregoli syndrome, intermetamorphosis syndrome, and SDD).

In a more recent 1991 paper in the journal Psychological Medicine, Dr. H. Forstl and his colleagues examined the psychiatric, neurological and medical aspects of 260 cases suffering misidentification syndromes. Among the sample SDD was relatively rare as 174 cases had a Capgras syndrome misidentifying other persons, 18 a Fregoli syndrome, 11 intermetamorphosis, 17 reduplicative paramnesia and the rest had other forms or combinations of mistaken identification (including SDD). The most common comorbid disorders among those who misidentified themselves or other were schizophrenia (n=127; mostly paranoid schizophrenia), affective disorder (n=29), and organic mental syndromes including dementia (n=46). The authors reported that:

“The misidentification of persons can be a manifestation of any organic or functional psychosis, but the misidentification of place is frequently associated with neurological diseases, predominantly of the right hemisphere. Misidentification syndromes show a great degree of overlap and do not represent distinctive syndromes nor can they be regarded as an expression of a particular disorder. These patients deserve special diagnostic and therapeutic attention because of the possible underlying disorders and their potentially dangerous behaviour”.

Finally, I thought I would leave you with a paper from a 2005 issue of the journal Psychopathology that reported some extreme cases involving delusional misidentification syndromes (DMS) and the danger associated with them. Dr. M. Aziz and his colleagues reported on three cases with histories of paranoid schizophrenia tall of who developed DMSs:

“Two of them acted out on delusional thinking toward their sons. Case 1 managed to kill her son and Case 2 was caught twice trying to choke him. Our case reports suggest that the degree of threat perceived by the patient from the delusionally misidentified object is the most important factor in determining the patient’s response to the delusions. Alcohol and substance intoxication facilitated the patients’ acting out on their delusions, but did not explain the genesis of the delusions. There is a need to continue to study patients with DMS in order to provide opportunity for greater understanding of the psychopathology of DMS”.

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

Further reading

Atwal, S., & Khan, M. H. (1986). Coexistence of Capgras and its related syndromes in a single patient. Australasian Psychiatry, 20, 496-498.

Aziz, M.A., Razik, G.N., & Donn, J.E. (2005). Dangerousness and management of delusional misidentification syndrome. Psychopathology, 38(2), 97-102.

Christodoulou, G.N. (1977). Treatment of the syndrome of doubles. Acta Psychiatrica Belgica, 77(2), 254-259.

Christodoulou, G.N. (1978). Syndrome of subjective doubles. American Journal of Psychiatry, 135, 249-251.

Christodoulou, G.N. (1978). Course and prognosis of the syndrome of doubles. Journal of Nervous and Mental Disease 166, 73-78.

Christodoulou, G.N., Margariti, M., Kontaxakis, V. P., & Christodoulou, N. G. (2009). The delusional misidentification syndromes: strange, fascinating, and instructive. Current Psychiatry Reports, 11(3), 185-189

Dictionary of Hallucinations (2013). Syndrome of subjective doubles. Located at:

Enoch, D., Ball, H. (2001). Uncommon Psychiatric Syndromes (Fourth Edition). London: John Wright & Sons.

Forstl, H.A.N.S., Almeida, O. P., Owen, A. M., Burns, A., & Howard, R. (1991). Psychiatric, neurological and medical aspects of misidentification syndromes: A review of 260 cases. Psychological Medicine, 21, 905-910.

Joseph, A.B. (1986). Cotard’s syndrome in a patient with coexistent Capgras’ syndrome, syndrome of subjective doubles, and palinopsia. Journal of Clinical Psychiatry, 47, 605-606.

Sporn again: A brief look at the evolution of ‘metrosexuality’

Back in 1994, the journalist Mark Simpson coined the term ‘metrosexual’ in an article in the British newspaper The Independent. The Wikipedia entry on metrosexuality notes:

“Metrosexual is a neologism, derived from metropolitan and heterosexual, coined in 1994 describing a man (especially one living in an urban, post-industrial, capitalist culture) who is especially meticulous about his grooming and appearance, typically spending a significant amount of time and money on shopping as part of this. The term is popularly thought to contrast heterosexuals who adopt fashions and lifestyles stereotypically associated with homosexuals, although, by definition given by [Mark Simpson], a metrosexual ‘might be officially gay, straight or bisexual’”

To be honest, I had never come across the term metrosexual until 2005 (although I was well aware of the male grooming, vain, image conscious, and product-consuming males typified by ex-footballer David Beckham). I was doing some consultancy with an online poker firm about different types of poker player and the press campaign that followed the publication of my report was headlined ‘betrosexuals’ (because it highlighted gender swapping by online poker players – an area that I then went on to research more academically – see ‘Further reading’ below). It was only at this point I was told that ‘betrosexual’ was a play on the word ‘metrosexual’.

The reason I mention all of this is because earlier today I did a BBC radio interview about the rise of the ‘spornosexual’ (yet another term I had never heard of until I was asked to appear on the programme). ‘Spornosexual’ is another term coined by Mark Simpson (as noted in the Wikipedia entry):

“A neologism combining sports, porn, and metrosexual, and used to describe an aesthetic adopted by many men who consume both sports and pornography. The spornosexual style emphasises heavy, lean musculature, and certain kinds of tattooing. The term entered the popular lexicon through a 2014 Daily Telegraph article by Mark Simpson…In 2006, Mark Simpson already wrote about ‘sporno’ for Out Magazine: ‘whole new generation of young bucks, from twinky soccer players like Manchester United’s Alan Smith and Cristiano Ronaldo to rougher prospects like Chelsea’s Joe Cole and AC Milan’s Kaká, keen to emulate their success, are actively pursuing sex-object status in a postmetrosexual, increasingly pornolized world”.

In short (and according to an article in the Washington Post), spornosexuals are simply the “hyper-sexualized, body-obsessed cultural offspring of the metrosexual”.To be honest, reading this definition makes me think that ‘spornosexuals’ have been around for a few decades now as these types of men were well described at length by Bret Easton Ellis in his 1991 novel American Psycho (minus the tattooing). Simpson claimed in his recent article in the Daily Telegraph that metrosexuality had evolved and that the “new wave” had put the ‘sexual’ into ‘metrosexuality’, had become “totally tarty”, and that such men should be called ‘spornosexuals’. More specifically, Simpson claimed:

“With their painstakingly pumped and chiselled bodies, muscle-enhancing tattoos, piercings, adorable beards and plunging necklines it’s eye-catchingly clear that second-generation metrosexuality is less about clothes than it was for the first. Eagerly self-objectifying, second generation metrosexuality is totally tarty. Their own bodies (more than clobber and product) have become the ultimate accessories, fashioning them at the gym into a hot commodity – one that they share and compare in an online marketplace. This new wave puts the ‘sexual’ into metrosexuality. In fact, a new term is needed to describe them, these pumped-up offspring of those Ronaldo and Beckham lunch-box ads, where sport got into bed with porn while Mr Armani took pictures. Let’s call them “spornosexuals”…Glossy magazines cultivated early metrosexuality. Celebrity culture then sent it into orbit. But for today’s generation, social media, selfies and porn are the major vectors of the male desire to be desired. They want to be wanted for their bodies, not their wardrobe. And certainly not their minds”

I tracked down Simpson’s 2006 article on ‘sporno’ published in Out magazine in which he claimed sport was the “new gay porn” because (for instance) footballers like David Beckham and Freddie Ljungberg had posed for gay magazines. He also made reference to metrosexual Gavin Henson (“rugby’s answer to David Beckham”) who loves shaving his legs and wears fake tan on the pitch. Simpson claimed:

“Sporno-sport that acknowledges and exploits the voyeuristic, usually homoerotic, thrill that fit male bodies throwing themselves against other fit male bodies can generate is already the acceptable, ruddy-cheeked outdoor-broadcasting face of porn. At least in soccer- and rugby-playing pagan Europe and Australia but it can be only a matter of time before it conquers the God-fearing, football-playing United States too…Being equal opportunity flirts, today’s sporno stars want to turn everyone on. Partly because sportsmen, like porn stars, are by definition show-offs, but more particularly because it means more money, more power, more endorsements, more kudos. It acknowledges the consumerist, showbiz direction that sport is moving in and engorges and inflates their career portfolio to gargantuan proportions”.

Simpson asserted that Beckham was a household name in America because he was a sporno star (rather than sports star) due to his high profile body adorning adverts and fetishizing himself. Beckham’s masculinity had become commodified, and in our highly consumerist culture “envy and desire are almost indistinguishable”. As a father of two sons and a daughter, I do worry how the perfect body images they see in the print and broadcast media may affect their own self-esteem. Although I had often thought about the pursuit of bodily perfection in terms of my daughter’s adolescent development, it’s not something I had thought about in relation to my sons. As a psychologist that specializes in addictive and obsessive behaviour, I am only too aware of the rise in male eating disorders, but the rise of the metrosexual is likely to be a contributory factor. In the Washington Post article on spornosexuality, the journalist Abby Phillip interviewed the branding expert (and author of the 2006 book The Future of Men) Marian Salzman. Salzman claimed that metrosexuality had indeed involved but not in the way that Simpson hoped:

“The word metrosexual has outgrown Simpson’s narcissistic depiction and now transcends narrow stereotypes to describe a whole range of traits. And the metrosexuals themselves are now men who don’t unquestioningly assume that there’s just one way of being a man”.

Based on what I have read so far, I don’t think that the term ‘spornosexuality’ will catch the public’s imagination in the same way as metrosexuality (in fact, I’m yet to be convinced that spornosexuality is significantly different from metrosexuality). That doesn’t mean the stereotypes attributed to such a term don’t exist. However, the jury is out on if there will be any long-lasting psychological consequences of identifying oneself as a spornosexual.

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

Further reading

Daily Mirror (2005). Betrosexuals. August 12. Located at:

Griffiths, M.D., Parke, J., Wood, R.T.A. & Rigbye, J. (2010). Online poker gambling in university students: Further findings from an online survey. International Journal of Mental Health and Addiction, 8, 82-89.

Phillip. A. (2014). Step aside, metrosexuals, and make way for…the spornosexual man? Washington Post, June 10. Located at:

Salzman, M. (2006). The Future of Men: The Rise of the Übersexual and What He Means for Marketing Today. London: Palgrave.

Simpson, M. (2006). Sporno. Out, June 19. Located at:,0

Simpson, M. (2014). The metrosexual is dead. Long live the ‘spornosexual’. Daily Telegraph, June 10. Located at:

Wikipedia (2014). Metrosexual. Located at:

Wikipedia (2014). Spornosexual. Located at:

Wood, R.T.A., Griffiths, M.D. & Parke, J. (2007). The acquisition, development, and maintenance of online poker playing in a student sample. CyberPsychology and Behavior, 10, 354-361.

What’s up Doc? A beginner’s guide to Medical Student Syndrome

Most of you reading this will probably be aware of the psychosomatic condition of hypochondria (also known as hypochondriasis) in which individuals have a preoccupying fear of having a serious illness despite appropriate medical evaluations and reassurances that their health is fine. However, what you may not be aware of is there appears to be some empirical evidence that some particular sub-groups of people appear to suffer hypochondria-related disorders relating to the medical conditions they are studying educationally and/or vocationally.

One such condition is ‘Medical Student/s’ Syndrome’ (also referred to by many other names including ‘Medical Students’ Disease’, ‘Medical Student Disorder’, ‘Medical School Syndrome’, ‘Third Year Syndrome’, ‘Second Year Syndrome’ and ‘Intern’s Syndrome’), a frequently reported psychological condition among medical trainees that experience the symptoms of the disease or diseases they are studying. In a review of the relevant literature in a 2004 issue of the Journal of Curriculum Theory, Dr. Brian Hodges (2004) noted that Medical Student Syndrome (MSS) was first reported in the 1960s. A Wikipedia summary of MSS noted that:

“The condition is associated with the fear of contracting the disease in question. Some authors suggested that the condition must be referred to as nosophobia [a specific phobia, an irrational fear of contracting a disease], rather than ‘hypochondriasis’, because the quoted studies show a very low percentage of hypochondriachal character of the condition, and hence the term ‘hypochondriasis’ would have ominous therapeutic and prognostic indications. The reference suggests that the condition is associated with immediate preoccupation with the symptoms in question, leading the student to become unduly aware of various casual psychological and physiological dysfunctions; cases show little correlation with the severity of psychopathology, but rather with accidental factors related to learning and experience”.

Dr. Bernard Baars in his 2001 book In the Theater of Consciousness: The Workspace of the Mind writes:

“Suggestible states are very commonplace. Medical students who study frightening diseases for the first time routinely develop vivid delusions of having the ‘disease of the week’ – whatever they are currently studying. This temporary kind of hypochondria is so common that it has acquired a name, ‘medical student syndrome’”.

Dr. Hodges also suggested that in the 1960s:

“[The] phenomenon caused a significant amount of stress for students and was present in approximately 70 to 80 percent of students… papers written in the 1980s and 1990s conceptualized the condition as an illness in the psychiatric spectrum of hypochondriasis…Marcus found that the dream content of year two medical students frequently involved a preoccupation with personal illness. Marcus’s subjects reported many dreams in which they suffered illnesses of the heart, the eyes and the bowels, among others.. [Learning about a disease] creates a mental schema or representation of the illness which includes the label of the illness and the symptoms associated with the condition. Once this representation is formed, symptoms or bodily sensations that the individual is currently experiencing which are consistent with the schema may be noticed, while inconsistent symptoms are ignored”.

In a 1998 paper in The Lancet, Dr. Oliver Howes and Dr. Paul Salkovskis briefly reviewed the literature on MSS and reported the findings of two studies that had examined the condition. The first study claimed that approximately 70% of medical students had “groundless medical fears during their studies” and the second study found that 79% of randomly chosen medical students demonstrated a “history of medical student disease”. However, more interestingly, they also cited various other studies on non-medical students showing that various types of students not studying medicine also had high rates of hypochondria.

A study by Dr. Ingrid Candel and Dr. Harald Merckelbach examined whether the role of thought suppression and fantasy proneness were predictors of MSS complaints in 215 medical students. Summarizing the study in a 2001 issue of The Psychologist, Dr. Fiona Lyddy defined thought suppression as “the habitual tendency to suppress unpleasant thoughts, which can produce counterproductive hyperaccessibility of the worrying information” and that fantasy-prone individuals “often report physical sensations associated with fantasies or thoughts they have engaged in (e.g. if they had the thought that they might have a blood clot after flying, they might report feeling tightness in the leg muscles)”. Candel and Merckelbach hypothesised that those students that scored highly on both thought suppression and fantasy-proneness would be more likely to experience MSS. Just under one-third (30%) of the sample (n=65) reported various MSS complaints with 33 medical students reporting psychiatric, cardiac, pulmonary, and gastrointestinal complaints. The authors found that gender and age were not significant predictors of MSS but as hypothesised, both thought suppression and fantasy proneness strongly predicted MSS complaints (the strongest being fantasy proneness).

A study led by Dr. G. Singh and colleagues and published in a 2004 issue of the journal Medical Education examined whether being at medical school causes health anxiety and worry in British medical students compared to a control group of non-medical students (and hypothesizing that medical students were more likely to report such conditions). A total of 449 medical students and 485 non-medical students across four years of study (first year to fourth year) were surveyed. Health anxiety was assessed using the appropriately named Health Anxiety Questionnaire whereas worry was assessed using the Anxious Thoughts Inventory. Contrary to their hypotheses, no evidence was found that medical students were more health anxious and greater worriers than non-medical students. In fact, the authors reported that health anxiety was significantly lower in medical students in the first year and the fourth year than non-medical students and that worry was significantly lower in the medical students across all years of study. The authors therefore concluded that “medical students are not a cohort of preselected health-anxious people, nor are they ‘worriers’ [and that] medical education at a clinical level [mitigates] health anxiety in the medical student population”.

MSS has also been reported in cognate disciplines to medicine (such as psychology). In 1997, in the journal Teaching of Psychology, Dr. M. Hardy and Dr. L. Calhoun investigated psychological distress and MSS in a group of American undergraduate students studying abnormal psychology. Their research found that students that planned to major in psychology reported more worry about their psychological health than those planning not to major in psychology. Interestingly – but not a surprise to me – students that had previously undergone some kind of psychological treatment were more likely to intend to pursue an advanced degree in counseling or psychotherapy than those that had not received prior psychological treatment. The authors also claimed that the students that learned about various psychological disorders demonstrated (i) decreased anxiety about their own mental health, and (ii) increased likelihood of seeking out mental health services on the university campus for personal psychological distress.

A more 2011 recent paper (also published in Teaching of Psychology) by Dr. M. Deo and Dr. J. Lymburner investigated whether psychology students can suffer Psychology Student Syndrome (PSS) – a direct analogue to MSS. To do this, they looked at the relationship between self-ratings of psychological health and the number of courses that students took in psychopathology. In addition to standard personality tests, the undergraduate students were asked to rate their level of concern about suffering from symptoms of various psychological disorders. However, Deo and Lymburner found no evidence of PSS. However, they did report a positive correlation between neuroticism and psychological health anxiety. As a result of this finding, they recommended that lecturers on psychopathology courses need to be aware that their neurotic students may be at a higher risk for believing they have psychological problems.

Taken as a whole. The results of studies to date appear to be very mixed as to whether students are more prone to suffering hypochondria-like conditions related to the subjects (i.e., medicine, psychology) they are studying. Even if the rates of hypochondria are higher in medical and/or psychology students, it might be that these students seek out such courses because of pre-existing conditions they have or think they have. More research with bigger samples, better control groups, and better control for pre-existing psychological and/or medical problems are warranted as there does appear to be some evidence that such conditions exist even if there may be good explanations as to why.

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

Further reading

Baars, Bernard J. (2001). In the Theater of Consciousness: The Workspace of the Mind. Oxford University Press US.

Candel, I. & Merckelbach, H. (2003) Fantasy proneness and thought suppression as predictors of the medical student syndrome. Personality and Individual Differences, 35, 519–524.

Deo, M. S., & Lymburner, J. A. (2011). Personality traits and psychological health concerns: The search for Psychology Student Syndrome. Teaching of Psychology, 38, 155-157.

Hardy, M.S., & Calhoun, L.G. (1997). Psychological distress and the “medical student syndrome” in abnormal psychology students. Teaching of Psychology, 24, 192-193.

Hodges, B. (2004) Medical student bodies and the pedagogy of self-reflection, self-assessment, and self-regulation. Journal of Curriculum Theory, 20(2), 41-51.

Howes, O.D. & Salkovskis, P.M. (1998). Health anxiety in medical students. The Lancet, 351, 1332.

Hunter, R.C.A, Lohrenz, J.G., & Schwartzman, A.E. (1964). Nosophobia and hypochondriasis in medical students. Journal of Nervous and Mental Diseases, 130,147-152.

Lyddy, F. (2001). Medical Student Syndrome. The Psychologist, 16, 602.

Singh, G. (2006). Medical students’ disease: Health anxiety and worry in medical students. Stress and mental health in college students. New York, NY: Nova Science Publishers, 29-62

Singh, G., Hankins, M., & Weinman, J. A. (2004). Does medical school cause health anxiety and worry in medical students? Medical Education, 38(5), 479-481.

Wikipedia (2013). Medical students’ disease. Located at:’_disease

That’ll do icily: A brief look at pagophagia

In a previous blog on five ‘weird addictions’ I briefly mentioned pagophagia, a craving and compulsion for chewing ice. Pagophagia is a type of pica (which I also covered in a previous blog). Pica is defined as the persistent eating of non-nutritive substances for a period of at least one month, without an association with an aversion to food. Although the incidence of pagophagia appears to have increased over the last 30 years in westernized cultures, Dr. B. Parry-Jones (in a 1992 issue of Psychological Medicine) carried out some historical research and pointed out that both Hippocrates and Aristotle wrote about the dangers of excessive intake of iced water. Parry-Jones also noted that references to disordered eating of ice and snow were also recorded in medical textbooks from the sixteenth century. However, the first contemporary reference to pagophagia appears to have been a 1969 paper by Dr. Charles Coltman in the Journal of the American Medical Association entitled ‘Pagophagia and iron lack’.

Pagophagia is closely associated with iron deficiency anemia but can also be caused by other factors (biochemical, developmental, psychological, and/or cultural disorders). If pagophagia is due to iron deficiency (such as case studies of those with sickle cell anemia), it may sometimes be accompanied by fatigue (e.g., being tired even when performing normally easy tasks). Dr. Youssef Osman and his colleagues published a number of case reports of pagophagia in a 2005 issue of the journal Pediatric Haematology and Oncology including the case of a child with sickle cell anemia and rectal polyps (that caused a lot of bleeding and made the anemia worse):

“An 8-year-old Omani boy, a known case of sickle cell anemia…presented with history of craving for ice. The child was noticed over the last 4 months to like drinking very cold water and to open the deep freezer and scratch the ice and eat it. The parents tried to stop him from doing so, but they failed…The child was started on oral iron therapy…and his craving for ice was completely stopped. Meanwhile, the rectal polyp was removed surgically”.

Other potential health side effects include constant headaches (a ‘brain freeze’ similar to ‘ice cream headache’) and teeth damage although this is thought to be relatively rare. However, a recent paper by Dr. Yasir Khan and Dr. Glen Tisman in the Journal of Medical Case Reports highlighted the case of a 62-year-old Caucasian man who presented with bleeding from colonic polyps associated with drinking partially frozen bottled water.

Khan and Tisman also suggested that some people who are deficient in iron experience tongue pain and glossal inflammation (glossitis). Others claim that chewing ice may help those with stomatitis (i.e., inflammation of the mucous lining inside the mouth). A recent 2009 case study published by Dr. Tsuyoshi Hata and his colleagues in the Kawasaki Medical Journal, reported the case of a 37-year old Japanese women who ate copious amounts of ice to relieve the pain of temporomandibular joint disorder (i.e., chronic pain in the joint that connects the jaw to the skull). Khan and Tisman also claim that the classical symptoms of pagophagia have changed in the last 40 years since Dr. Coltman’s initial paper in the Journal of the American Medical Association.

“This may probably be the result of advances in technology and changes in culture. When initially described [by Coltman], pagophagia was defined as the excessive ingestion of ice cubes from ice trays and the ingestion of ice scraped from the wall of the freezer. With the advent of ice cube makers and auto defrosters, the presentation of pagophagia has changed in a subtle manner as described in…our patients. Now we observe a subtler ingestion and/or sucking of ice cubes from large super-sized McDonalds-like cups and from the use of popular bottled water containers that have been frozen”.

There have been few epidemiological studies examining the prevalence of pagophagia. Such estimates vary widely within particular populations but (according to Dr. Youssef Osman and his colleagues) have been shown to be more common in low socioeconomic and underdeveloped areas. Pagophagia is thought to be relatively harmless in itself or to one’s health, although there are some claims in the literature that pagophagia can be addictive. However, empirical reviews suggest that pagophagia (and pica more generally) is part of the obsessive-compulsive disorder spectrum of diseases. As a consequence, some case studies even suggest that ice chewing compromises their ability to maintain jobs or personal relationships.

Treatment for pagophagia can often be overcome with iron therapy and Vitamin C supplements (to supplement iron deficiency if that is the cause). For instance, Dr. Mark Marinella in a 2008 issue of the Mayo Clinic Proceedings successfully treated a 33-year old woman with pagophagia following complications with gastric bypass surgery:

“The patient received red blood cells, iron sucrose, and levofloxacin. On further questioning, the patient denied taking vitamin, mineral, or iron supplements since surgery and reported prolonged, heavy menstrual cycles. She consumed large amounts of ice daily for several months. The patient’s husband frequently observed her in the middle of the night with her head in the freezer eating the frost off the icemaker. The patient admitted to awakening several times nightly for months with an uncontrollable compulsion to eat the frost on the icemaker. This craving resolved after transfusion and iron administration”

However, if the condition is psychologically or culturally based, iron and vitamin supplements are unlikely to work, and other psychological treatments (such as cognitive-behavioural therapy) are likely to be employed.

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

Further reading

Coltman, C.A. (1969). Pagophagia and iron lack. Journal of the American Medical Association, 207, 513-516.

de Los Angeles, L., de Tournemire, R. & Alvin, P. (2005). Pagophagia: pica caused by iron deficiency in an adolescent. Archives of Pediatrics, 12, 215-217.

Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemadej, U.J., Cole, O.J., Westney, O.E., Jones, S. Laryea, H. & Westney, L.S. (1994). Pica in an urban environment. Journal of Nutrition (Supplement), 124, 954-962.

Hata, T., Mandai, T., Ishida, K., Ito, S., Deguchi, H. & Hosoda, M. (2009). A rapid recovery from pagophagia following treatment for iron deficiency anemia and TMJ disorder accompanied by masked depression. Kawasaki Medical Journal, 35, 329-332.

Khan, Y. & Tisman, G. (2010). Pica in iron deficiency: A case series. Journal of Medical Case Reports, 4, 86. Located:

Kirchner, J.T (2001). Management of pica: A medical enigma. American Family Physician, 63, 1177-1178.

Marinella, M. (2008). Nocturnal pagophagia complicating gastric bypass. Mayo Clinic Proceedings, 83, 961

Osman, Y.M., Wali, Y.A. & Osman, O.M. (2005). craving for ice and iron-deficiency anemia: a case series. Pediatric Hematology and Oncology, 22, 127-131.

Parry-Jones, B. (1992). Pagophagia, or compulsive ice consumption: A historical perspective. Psychological Medicine, 22, 561-571.

A burning for earning: A brief look at ‘wealth addiction’

Back in 1996, I published a paper on behavioural addictions in the Journal of Workplace Learning. One of my introductory paragraphs in that paper noted:

“There is now a growing movement (e.g. Miller, 1980; Orford, 1985) which views a number of behaviours as potentially addictive, including many behaviours which do not involve the ingestion of a drug. These include behaviours diverse as gambling (Griffiths, 1995), overeating (Orford, 1985), sex (Carnes, 1983), exercise (Glasser, 1976), computer game playing (Griffiths, 1993a), pair bonding (Peele and Brodsky, 1975), wealth acquisition (Slater, 1980) and even Rubik’s Cube (Alexander, 1981)! Such diversity has led to new all encompassing definitions of what constitutes addictive behaviour”.

The reason I mention this is that I was recently asked to comment on a story about ‘wealth addiction’ and I vaguely remembered that I had mentioned (in passing) Philip Slater’s 1980 book (also entitled Wealth Addiction). Slater’s book was written from a sociological standpoint and was both controversial and provocative. Slater claimed on the book cover that: ““Money is America’s most powerful drug. Here’s how it weakens us and how we can free ourselves”. I also came across an interesting 2012 article by journalist Scott Burns (on ‘wealth addiction revisited’) who noted that:

“One of the hallmarks of wealth addiction is very simple: more possessions but less use. We become so interested in possessing the thing that we lose the experience it provides. This can be as vast as owning homes all around the world, as some of the very rich do, as simple as Bernie Madoff’s shoe collection, or as obsessive as a collection of rare watches. Whatever it is, the wealth addict confuses possession with experience”.

Slater argued that our increasing reliance on money and all of the things that it can buy has the potential to become an obsession that can destroy individual lives. According to short article by Dr. Paul Hokemeyer, wealth addiction has three key characteristics:

  • Tolerance: More and more money is needed to attain a baseline level of satisfaction.
  • Withdrawal: The thought of losing money or not making it fills a person with fear, anxiety and stress.
  • Negative consequences: In their pursuit of money, the person forgoes emotional fulfillment, intimate relationships and peace of mind.

These are actually three of the six criteria that I personally believe comprise genuine addictive behaviour (although I use the word ‘conflict’ rather than ‘negative consequences’; the other three criteria are salience, mood modification and relapse – see my previous blog on behavioural addiction for further details).

The reason why wealth addiction has made a re-appearance over the last month is because of an article published in the New York Times by Sam Polk, a former hedge fund trader that worked on Wall Street (and who since the article has been published has been compared to Jordan Belfort, the person that Leonardo DiCaprio portrayed in the true story film The Wolf of Wall Street).

Polk’s article is an interesting read (whether you think wealth addiction exists or not) and I thought I would pick out some of the text and relate it to my own views about what constitutes addictive behaviour.

  • Extract 1: “In my last year on Wall Street my bonus was $3.6 million – and I was angry because it wasn’t big enough. I was 30 years old, had no children to raise, no debts to pay, no philanthropic goal in mind. I wanted more money for exactly the same reason an alcoholic needs another drink: I was addicted”

Here, Polk refers to his work bonuses becoming bigger and bigger and that they were never enough. To me, this sounds like some kind of tolerance effect with more and more money needed to achieve the desired (presumably mood modifying effect). Polk also claims – after the fact – that he had become addicted.

  • Extract 2: “I was also a daily drinker and pot smoker and a regular user of cocaine, Ritalin and ecstasy. I had a propensity for self-destruction that had resulted in my getting suspended from Columbia for burglary, arrested twice and fired from an Internet company for fist fighting”.

Polk openly discusses his previous use of potentially addictive substances and made the comparisons himself between his self-confessed behavioural (wealth) addiction and his previous self-destructive chemical abuse. Some readers may jump to the conclusion that Polk had (or has) an ‘addictive personality’ but this is not something that I personally believe in. To me, Polk is displaying ‘reciprocity’ (swapping one potential addiction with another) rather than being a function of an underlying personality trait. Giving up one addiction often leaves a large void and sometimes the only way to fill it is by engaging in other behaviours that provide similar feelings and sensations.

  • Extract 3: “My counselor didn’t share my elation [at earning more and more money]. She said I might be using money the same way I’d used drugs and alcohol – to make myself feel powerful — and that maybe it would benefit me to stop focusing on accumulating more and instead focus on healing my inner wound”.

Here, Polk’s therapist appears to hit the nail on the head in relation to what money represented for Polk. I would describe the feeling that Polk gained from both drugs and money was omnipotence (something that I have also written about in relation to my research on gambling).

  • Extract 4: “I was terrified of running out of money and of forgoing future bonuses. More than anything, I was afraid that five or 10 years down the road, I’d feel like an idiot for walking away from my one chance to be really important. What made it harder was that people thought I was crazy for thinking about leaving. In 2010, in a final paroxysm of my withering addiction, I demanded $8 million instead of $3.6 million. My bosses said they’d raise my bonus if I agreed to stay several more years. Instead, I walked away”.

Polk’s language here is very much rooted in what addicts say about their drug or behaviour of choice (“terrified” of being without the thing they love doing). The weighing up of the costs clearly led to a decision for Polk to quit his “withering addiction” and there are obviously signs both here (and the rest of the article if you read it) that leaving behind the wealth left him with some feelings of regret.

  • Extract 7: “The first year was really hard. I went through what I can only describe as withdrawal — waking up at nights panicked about running out of money, scouring the headlines to see which of my old co-workers had gotten promoted. Over time it got easier — I started to realize that I had enough money, and if I needed to make more, I could. But my wealth addiction still hasn’t gone completely away. Sometimes I still buy lottery tickets”.

Here, Polk uses addictive terminology (i.e., withdrawal) to describe giving up the activity that led to him gaining wealth. Again, the fear of running out of money appears psychologically similar to the fear that other more traditional addicts have about running out of their drug of choice. It could also be argued that he has given up one form of gambling (financial trading) with partially doing another (buying lottery tickets).

  • Extract 8: “I was lucky. My experience with drugs and alcohol allowed me to recognize my pursuit of wealth as an addiction. The years of work I did with my counselor helped me heal the parts of myself that felt damaged and inadequate, so that I had enough of a core sense of self to walk away”

Polk uses his experiences in giving up drugs with the help of his therapist as a way of helping him give up wealth acquisition. Knowing you have managed to give up one addiction shows that you have the mental strength to give up another.

Obviously I have never met Polk and I can only go on how he described his experiences during his time on Wall Street, However, the insights shared do seem to suggest that some of the wealth acquisition behaviour had addictive elements and that there was at least some evidence that Polk – at least on some occasions – experienced salience, tolerance, withdrawal, conflict and mood modification. Whether he was genuinely addicted to money in the same way as drug addicts are addicted to psychoactive substances is debatable. However, theoretically, I can see how someone might be become addicted to wealth. There are also interesting questions as to whether wealth acquisition may be an underlying motivation for those addicted to work.

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

Further reading

Alexander, R. (1981). A cube popular in all circles. New York Times, 21 July, p. C6.

Burns, S. (2012). Beyond envy: Wealth addiction revisited. Dallas News, December 15: Located at:

Carnes, P. (1983). Out of the Shadows: Understanding Sexual Addiction. CompCare, New York, NY.

Glasser, W. (1976). Positive Addictions. Harper & Row, New York, NY.

Griffiths, M.D. (1993). Are computer games bad for children? The Psychologist: Bulletin of the British Psychological Society, 6, 401-407.

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

Orford, J. (1985). Excessive Appetites: A Psychological View of the Addictions. Wiley: Chichester.

Peele, S. and Brodsky, A. (1975). Love and Addiction. Taplinger: New York, NY.

Polk, S. (2013). For the love of money. New York Times, January 29. Located at:

Slater, P. (1980). Wealth Addiction. E.P. Dutton: New York, NY.


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