Turn on the eating: A beginner’s guide to sexual cannibalism

“People who have consumed human blood and flesh reportedly claim to experience an intoxicating euphoric effect. This reaction is similar to that experienced by anyone who satisfies a strong sexual craving that is not considered normal (exhibitionism, necrophilia, rape, etc.). However, in this case, it must have reinforced the beliefs of worshippers that indeed their god was present in the victim” (Dr. Brenda Love, Encyclopedia of Unusual Sex Practices).

Today’s blog takes a brief look at sexual cannibalism in humans. I added “in humans” at the end of the sentence because sexual cannibalism is quite common in some animal species. As Dr. Brenda Love notes in her Encyclopedia of Unusual Sex Practices, sexual cannibalism is known to occur in some types of spider, praying mantis, scorpion, cricket, grasshopper, and fly. The Wikipedia entry also notes that sexual cannibalism has been observed in various types of crustacean (e.g., amphipods, copepods), slugs and snails (i.e., gastropods), and squids and octopuses (i.e., cephalopods). In the non-human species, it is typically the female that kills and eats the male before, during or after sexual union has taken place. Amongst humans, sexual cannibalism is extremely rare, and most humans who engage in cannibalistic acts for sexual purposes are generally considered sociopaths.

Of course, cannibalism for non-sexual purposes – known I more scientific circles as anthropophagy – has long been known among certain tribes and cultures. Throughout history, cannibalism has been practiced in many forms across Asia, Australia, Europe, and the Americas. Though rare today, it is believed to be still practiced in a few remote parts of Asia.  Cannibalism can be classed as either endocannibalism (i.e., consumption of another human being from within the same group or community) or exocannibalism (i.e., consumption of another human being from outside the group or community). Some acts of endocannibalism are actually acts of necro-cannibalism (i.e., the eating of flesh from dead humans also known as necrophagy) where dead people’s body parts are eaten as either part of the grieving process, as a way of guiding the souls of the dead into the bodies of the living, and/or as a way of imbibing the dead person’s ‘life force’ or more specific individual characteristics. Such endocannibalistic practices were common among certain tribes in New Guinea (which led to the prion disease kuru that I examined in a previous blog). However, it is known that many males among various tribes would not consume females for fear of emasculation. Exocannibalistic acts were most often carried out as part of a celebration victory after battles with rival tribes. There are various theories from many perspectives on why cannibalism may occur. These have included:

• Religious theories (e.g., religious beliefs involving the need to eat human flesh as a way of sustaining the universe or as part of magical and ritualistic ceremonies).
• Political theories (e.g., eating human flesh as a political tool to intimidate and control potential hostiles or subordinates).
• Socio-psychological theories (e.g., eating human flesh due to unconscious factors such as a response to trauma).
• Ecological theories (e.g., eating human flesh as a way of controlling the size of the population. The Aztecs were said to have eaten no less than 15,000 victims a year as – some have argued – a form of population control).
• Dietary theories (e.g., eating human flesh as a source of protein).

There are of course other reasons (including sexual ones) that may be the root of someone’s cannibalistic desire to eat human flesh. One reason could be out of necessity. For instance, in 1972, a rugby team from Uruguay was in a plane crash in the Andes. Fifteen people died and the only way they prevented themselves starving to death was to eat the flesh of the deceased (which given the fact it took 72 days for them to be rescued, was one of the few viable options to prevent starvation). At its simplest level, human sexual cannibalism is usually considered a psychosexual disorder and involves individuals’ sexualizing (in some way) the consumption of another human being’s flesh. One online article claims that:

“This does not necessarily suggest that the cannibal achieves sexual gratification only in the act of consuming human flesh, but also may release sexual frustration or pent up anger. Sexual cannibalism is considered to be a form of sexual sadism and is often associated with the act of necrophilia (sex with corpses)”.

When it comes to sexual cannibalism in humans, there are arguably different subtypes (although this is based on my own personal opinion and not on something I’ve read in a book or research paper). Most of these behaviours I have examined in previous blogs (so click on the links if you want to know more:

• Vorarephilia is a sexual paraphilia in which individuals are sexually aroused by (i) the idea of being eaten, (ii) eating another person, and/or (iii) observing this process for sexual gratification. However, most vorarephiles’ behaviour is fantasy-based, although there have been real cases such as Armin Meiwes, the so-called ‘Rotenburg Cannibal’.
• Erotophonophilia is a sexual paraphilia in which individuals have extreme violent fantasies and typically kill their victims during sex and/or mutilate their victims’ sexual organs (the latter of which is usually post-mortem). In some cases, the erotophonophiles will eat some of their victim’s body parts (usually post-mortem). Many lust murderers – including Jack the Ripper – are suspected of engaging in cannibalistic and/or gynophagic acts, taking away part of the female to eat later. Other examples of murderers who have eaten their victims (or parts of them) for sexual pleasure include Albert Fish, Issei Sagawa, Andrei Chikatilo, Ed Gein, and Jeffrey Dahmer.
• Sexual necrophagy refers to the cannibalizing of a corpse for sexual pleasure. This may be associated with lust murder but Brenda Love in her Encyclopedia of Unusual Sex Practices says that such cases usually involve “one whose death the molester did not cause. Many cases of reported necrophilia include cannibalism or other forms of sadism and it is believed that many others fantasize about doing it”.
• Vampirism as a sexual paraphilia in which an individual derives sexual arousal from the ingestion of blood from a living person
• Menophilia is a sexual paraphilia in which an individual (almost always male) derives sexual arousal from drinking the blood of menstruating females.
• Gynophagia is (according to Dr. Anil Aggrawal’s 2009 book Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices) a sexual fetish that involves fantasies of cooking and consumption of human females (gynophagia literally means “woman eating”). There is also a sub-type of gynophagia called pathenophagia. This (according to Dr. Brenda Love) is the practice of eating young girls or virgins. Several lust murderers were known to consume the flesh of young virgins, most notably Albert Fish). 

Added to this list, is something I would call ‘sexual autophagy’ which refers to the eating of one’s own flesh for sexual pleasure (and would be a sub-type of autosarcophagy discussed in a previous blog). I am basing this sub-type on an entry I came across in Brenda Love’s Encyclopedia of Unusual Sex Practices and relating to a case study reported by Krafft-Ebing:

“Krafft-Ebing recorded the case of a man who at 13 [years of age] became infatuated with a young white-skinned girl. However, instead of desiring intercourse, he was overwhelmed by the urge to bite off a piece of her flesh and eat it. He began stalking women, and for years he carried a pair of scissors with him. He was never successful in accosting a woman, but when he came close he would cut off and eat a piece of his own skin instead. This act produced an immediate orgasm for him”.

This account seems to be confirmed by some online articles on sexual cannibalism claiming that cannibals feel a sense of euphoria and/or intense sexual stimulation when consuming human flesh. All of these online accounts cite the same article by Clara Bruce (‘Chew On This: You’re What’s for Dinner’) that I have been unable to track down (so I can’t vouch for the veracity of the claims made). Bruce’s article claimed that cannibals had compared eating human flesh with having an orgasm, and that flesh eating caused an out-of-body-experience experience with effects comparable to taking the drug mescaline. In another publication that I’ve failed to track down, the following snippet appears on at least 20 websites with articles on sexual cannibalism:

“Lesley Hensel, author of ‘Cannibalism as a Sexual Disorder’ [says] eating human flesh can cause an increase in levels of vitamin A and amino acids, which can cause a chemical effect on the blood and in the brain. This chemical reaction could possibly lead to the altered states that some cannibals have claimed to have experienced. However, this theory has not been substantiated by scientific evidence”.

As I’ve covered many of the cannibalistic sub-types in previous blogs, I tried to do some further research on gynophagia. There is almost nothing written from an academic or clinical perspective about gynophagia (in fact when I typed in ‘gynophagia’ only one reference turned up – a paper on ‘the psychophysical basis of feelings’ published by Dr. C.L. Herrick in an 1892 issue of the Journal of Comparative Neurology that only mentioned gynophagia in passing). However, there are quite a few dedicated gynophagia websites out there including dedicated pages on the Deviant Art website and an interesting set of cannibalistic links (that you can check out for yourself on the Indie Film website. There is also a reasonably lengthy article in the Urban Dictionary but it features little of any substance. The person writing the article makes the following observations:

“Gynophagia is the fetish of a person becoming food for someone else as a fantasy. As a fantasy it’s just as taboo as BDSM or other kinks…Gynophagia can really be a more gentle fetish than BDSM because torture is almost never applied. Honestly, when you boil it down to its essentials (no pun intended), gynophagia is an extension of the ‘Damsel in Distress’ scenario…Gynophagia is present in a lot of the older media we have, the most widely recognized being a helpless woman being boiled alive by a native tribe when the hero rescues her. Another example would be in Little Red Riding Hood where the wolf devours Red Riding Hood, but this could also be classified as a separate but similar fetish called Vorarephillia. One of the more widely known scenarios of gynophagia is known as the Dolcett method which usually centers around the main female character of a Dolcett comic being spit roasted alive and enjoying every moment of it. But again I must stress that gynophagia is one of those few fetishes that can only be a fantasy and should not be practiced in real life”.

If you really want to find out what gynophagia disciples are into, I suggest you check out the Carnal Consummations fetish website (but you’ve been warned!).

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.

Arens, William (1979). The Man-Eating Myth: Anthropology and Anthropophagy. Oxford: Oxford University Press.

Beier, K. (2008). Comment on Pfafflin’s (2008) “Good enough to eat”. Archives of Sexual Behavior, 38, 164-165.

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

Cannon, J. (2002). Fascination with cannibalism has sexual roots. Indiana Statesman, November 22. Located at: http://www.indianastatesman.com/vnews/display.v/ART/2002/11/22/3dde3b6201bc1

Krafft-Ebing, R. von (1886). Psychopathia sexualis (C.G. Chaddock, Trans.). Philadelphia: F.A. Davis.

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

Pfafflin, F. (2008). Good enough to eat. Archives of Sexual Behavior, 37, 286-293.

Pfafflin, F. (2009). Reply to Beier (2009). Archives of Sexual Behavior, 38, 166-167.

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

Unlimited Blog (2007). Sexual cannibalism and Nithari murders. November. Located at: http://sms-unlimited.blogspot.co.uk/2007/11/sexual-cannibalism-and-nithari-murders.html

Wikipdia (2012). Cannibalism. Located at: http://en.wikipedia.org/wiki/Cannibalism

Wikipedia (2012). Human sacrifice in Aztec culture. Located at: http://en.wikipedia.org/wiki/Human_sacrifice_in_Aztec_culture

Wikipedia (2012). Sexual cannibalism. Located at: http://en.wikipedia.org/wiki/Sexual_cannibalism

Brain food: A beginner’s guide to kuru

In a previous blog, I examined the scientific literature on fatal familial insomnia (FFI), an incredibly rare genetic sleep disorder cause caused by a genetic mutation that leads to prion disease. Today’s blog takes a brief look at another prion disease – ‘kuru’. Like FFI, kuru is also an incurable and degenerative neurological disorder (i.e., a transmissible spongiform encephalopathy) although the only people known to have experienced it are a few cannibalistic tribes in the Eastern Highlands Province of New Guinea (most notably the Fore tribe) where it is known as the ‘laughing sickness’ or the ‘laughing disease’ (that refer to one of the disease’s most noticeable symptoms – the hysterical and pathological outbursts of laughter that suffering individuals produce in the latter stages of the disease).

The disease has a relatively long incubation period (5 to 20 years, with an average of 10 to 13 years according to a study led by Dr. Jerome Huillard d’Aignaux in a 2002 issue of the journal Epidemiology. However, a study published by Dr. R.L. Klitzman and colleagues in an earlier issue of Neuroepidemiology reported that:

“Epidemiological data were collected on…65 kuru patients who died or were diagnosed between 1977 and 1981. From these…2 or more participants were exposed to the infectious agent for the first time and died within weeks or months of each other 25–30 years later. Thus, it is shown that the natural incubation period of kuru could be as long as 25–30 years”

A more recent paper by Dr. John Collinge and colleagues in The Lancet identified 11 kuru sufferers from July 1996 to June 2004 all living in the South Fore. They reported that the minimum estimated incubation periods ranged from 34 to 41 years. However, they also noted that the likely incubation periods in men ranged from 39 to 56 years and could have been up to 7 years longer. Therefore, incubation periods could be very long.

According to Dr. Robert Will (in a 2003 issue of the British Medical Bulletin), over 2700 cases of kuru have been recorded since 1957 (in a total population within the kuru region of 36,000 people). Those infected with kuru typically die between 3 and 24 months following the first symptoms. Because of the long incubation period, it is thought that the last person to die of kuru in New Guinea was only seven years ago (i.e., 2005).

The word ‘kuru’ (not to be confused with ‘koro’, the culture bound genital retraction syndrome typically found in south-east Asia) is derived from the Fore tribe’s word ‘to shake’ (‘kuria’). Research carried out in the 1960s and 1970s demonstrated beyond doubt that kuru was transmitted from one individual to another via the cannibalistic practices of the Fore tribe (particularly the South Fore of the Okapa Subdistrict that showed the most large and notable kuru infection rates). The first recorded cases of kuru were made by a number of Australians back in the early 1950s. W.T. Brown reported that

“The first sign of impending death is a general debility which is followed by general weakness and inability to stand. The victim retires to her house. She is able to take a little nourishment but suffers from violent shivering. The next stage is that the victim lies down in the house and cannot take nourishment and death eventually ensues”.

It was in the early 1960s at the Eastern Highlands Awande Hospital that kuru sufferers underwent medical research in an effort to locate the cause of the disease. It was the pioneering work Daniel Gajdusek and Michael Alpers that led to the discovery of the causative agent of kuru. Brain tissue samples were taken from an 11-year old girl who had died of kuru and subsequently injected into a couple of chimpanzees. One of the chimps developed kuru within 24 months, and the research showed unequivocally that kuru was capable of infection cross-species. According to Dr. Robert Will, “this seminal discovery led to the successful laboratory transmission of [Creutzfeldt-Jakob disease] and initiated research into the epidemiology and pathogenesis of human prion disease”

It is now generally believed that the kuru outbreak began following the consumption of an infected human brain with sporadic Creutzfeldt-Jakob disease (CJD) by people in the Fore tribe in around 1900. Kuru then spread to other nearby tribes following inter-tribe marrying (gradually spreading to the 169 villages and hamlets according to a 2010 paper by Dr. Nils Pedersen and Dr. Else Smith in a 2010 issue of Acta Pathologica Micobiologica Et Immunologica Scandinavica). Once infected with kuru, the disease has three distinct phases (ambulant, sedentary, and terminal):

• Ambulant phase: Symptoms typically include decreased muscle and motor control leading to an unsteady gait and stance, tremors, and deterioration and slurring of speech (dysarthria).
• Sedentary phase: Symptoms typically include deterioration of muscle coordination (ataxia) and severe tremors. Sufferers are unable to walk unaided and they suffer bouts of hysterical and uncontrolled laughter.
• Terminal phase: Symptoms typically include complete loss of muscle co-ordination, incontinence, being unable to talk or sit unaided, great difficulty in swallowing food (dysphagia) (difficulty swallowing), and the outbreak of necrotic ulcerations (sores with pus).

The early research by Michael Alpers and colleagues showed that kuru spread very rapidly as a result of the Fore tribe’s endocannibalistic practice (i.e., of eating the flesh of human beings from within the same community after the person had died and taking on that individual’s ‘life force’). Interestingly, Alper’s research also showed that kuru infection was far more prevalent in women and children (in fact, up to 9 times more prevalent). Dr. Pedersen and Dr. Smith noted that the youngest ever kuru sufferer was five years old, and that 67% of those with kuru were adult women, 23% were children and adolescents, and only 10% were adult men.

There are two reasons why kuru might be more prevalent among women and children compared to men. Firstly, men in the tribe had first choice of which parts of the infected dead tribe member to eat. Once the men had eaten the ‘choice cuts’, women and children could only eat what was left and this included the dead person’s brain (where the infected prion particles were at their most concentrated). Secondly, women and children were far more likely than men to clean the bodies of the infected dead people. If those cleaning the body had open cuts or sores on their hands, the infection may have spread through the bloodstream. The 2002 research led by Dr. Jerome Huillard d’Aignaux and colleagues also demonstrated that the incubation period in females was shorter than that in males because adult women may have been exposed to the largest doses of infectious material. However, Dr. Robert Will has noted that as time has passed, the incidence of kuru has declined and the proportion of affected adult males and females has become more similar. Research (for example by Dr. Simon Mead) has also indicated that some members of the Fore tribe were immune from catching kuru as they carried a prion-resistant factor. Dr. Will also reported that:

“No children born after 1959 have been affected and there is no evidence of vertical transmission of infectivity in kuru, despite the breast-feeding of infants by many hundreds of clinically affected mothers”.

Most recent papers on kuru (such as one by Dr. Laura Manuelidis and colleagues in a 2009 issue of Proceedings of the National Academy of Sciences) have noted that the disease has now died out due to the cessation of the endocannibalistic rituals and therefore is not created spontaneously by the human host.

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

Further reading

Collinge, J., Whitfield, J.W., McKintosh, E., Beck, J., Mead, S., Thomas, D.J., & Alpers, M.P. (2006). Kuru in the 21st century—an acquired human prion disease with very long incubation periods. The Lancet, 367, 2068-2074.

Gajdusek, D.C., Gibbs, C.J. & Alpers, M. (1966). Experimental transmission of a Kuru-like syndrome to chimpanzees. Nature, 209, 794-796.

Gajdusek, D.C & Zigas, V. (1957). Degenerative disease of the central nervous system in New Guinea. The epidemic occurrence of ‘‘Kuru’’ in the native population. New England Journal of Medicine, 257, 974-978.

Huillard d’Aignaux, J.N., Cousens, S.N., Maccario, J., Costagliola, D., Alpers, M.P., Smith, P.G., Alpérovitch, A. (2002). The incubation period of kuru. Epidemiology, 13, 402-408.

Klitzman, R.L., Alpers, M.P. & Gajdusek, D.C. (1984). The natural incubation period of kuru and the episodes of transmission in three clusters of patients. Neuroepidemiology, 3, 3-20.

Lindenbaum, S. (1979). Kuru sorcery: Disease and danger in the New Guinea highlands. Palo Alto, CA: Mayfield.

Manuelidis, L., Chakrabarty, T., Miyazawa, K., Nduom, N. & Emmerling, K. (2009). The kuru infectious agent is a unique geographic isolate distinct from Creutzfeldt–Jakob disease and scrapie agents Proceedings of the National Academy of Sciences, 106, 13529-13534.

Pedersen, N.S. & Smith, E. (2010). Prion diseases: Epidemiology in man. Acta Pathologica Micobiologica Et Immunologica Scandinavica, 110, 14-22.

Will, R.G. (2003). Acquired prion disease: iatrogenic CJD, variant CJD, kuru. British Medical Bulletin, 66, 255-265.

Things that go bump: A brief overview of Couvade Syndrome

In a previous blog, I briefly reviewed a number of different types of pregnancy delusion. One of the more interesting of these and somewhat controversial male psychological conditions that have been reported relatively frequently in the psychological research literature is Couvade syndrome (sometimes called sympathetic pregnancy) but is not generally recognized as a bone fide medical condition. There are two derivations of the name. The first derives from the French verb ‘couver’ meaning ‘to brood, to hatch’). The second derivation comes from a misunderstanding of the idiom ‘faire la couvade’ (“to sit doing nothing”). The term is over 150 years old and was used by Edward Burnett Taylor (an English anthropologist) to describe cross-cultural fatherhood rituals during their partners’ pregnancies. For instance, in 1865, Taylor described various cultures where it was the father who took to bed with labour pains while the pregnant mother continued to work in the fields. Taylor also described how the midwife stayed with the father rather than the mother.

Most health practitioners would agree that it appears to be a more psychosomatic condition and occurs when males appear to experience similar symptoms to that of their pregnant partner. Some of the more commonly reported symptoms have included morning sickness, increased or decreased appetite, strange food cravings, toothache, sleep disturbances (e.g., insomnia), indigestion, diarrhea, constipation, backache, hormone level fluctuations, nosebleeds, and weight gain. In more extreme cases, there have been reports of sympathetic stomach and labour pains, breast changes, breast secretions, hardening of the nipples, and postnatal depression. In these extreme cases, there are reports of expectant fathers gaining up to 30 pounds in weight and growing a belly similar to a 7-month pregnant woman (the so-called ‘false pregnancy syndrome’).

A paper by Dr. S. Masoni and colleagues in the Journal of Psychosomatic Obsteterics and Gynecology noted that thesevarious symptoms have been described in the partners of pregnant women with an incidence ranging from 11% to 65%, and that the most common of these symptoms were (a) appetite variations, (b) nausea, (c) insomnia and (d) weight gain. Physiological studies (such as those by Dr. A. Storey and his colleagues published in the journal Evolution and Human Behavior) have indicated that males living with their pregnant partners show sympathetic hormonal changes in cortisol, testosterone, estradiol, and prolactin, across the pregnancy and a few weeks after birth.

Dr. Arthur Brennan and colleagues carried out a critical review of the Couvade Syndrome in a 2007 issue of the Journal of Reproductive and Infant Psychology. They noted that the syndrome was a global phenomenon occurring in many industrialised countries worldwide but had wide international variance on terms of the symptoms that men displayed. Their review asserted that expectant fathers were most affected during the first and third trimesters of their partner’s pregnancy. They concluded that the syndrome’s relationship with socio‐demographic factors was “inconsistent, with the exception of ethnicity”. However, they also make the point that the differences in findings may simply “reflect methodological problems in the syndrome’s definition or criteria and type of measurement across studies”.

There are no definitive explanations for Couvade Syndrome but there have been no shortage of theories. In a 1991 issue of the International Journal of Psychiatry Medicine, Dr H. Klein overviewed several psychological theories. Reasons as to why men experienced sympathetic pregnancy symptoms included pregnancy envy, pseudo-sibling rivalry, paternal ambivalence, and paternal identification with the unborn baby. More specifically, psychodynamic theories argue that men are envious of their partner’s ability to procreate or that they are becoming rivals for the pregnant woman’s attention. However, Klein sits on the fence somewhat and concludes that: “It is likely that the dynamics of couvade may vary between individuals and may be multi-determined”. Evolutionary psychologists speculate it is about the minimizing of gender differences and/or balancing of gender roles. The critical review by Brennan and his associates rightly pointed out that these theories have not been systematically investigated, and those that have been examined haven’t shown consistent findings. In one online summary of the disorder, it has also been noted that in some cultures, Couvade symptoms are often attributed to attempts at keeping spirits and demons from the mother or seeking favour of supernatural beings for the child.

The same authors also recommended that future research should utilize qualitative approaches to further uncover “the syndrome’s characteristics, definition and perceptions as seen by male partners”. They then followed their own recommendation and published a qualitative study (again in the Journal of Reproductive and Infant Psychology) interviewing 14 expectant fathers with pregnant partners aged 19–48 years (across different social and ethnic backgrounds). Their interviews revealed some key themes including (i) ‘Nature, Management and Duration of Symptoms’ (physical symptoms were more commonplace than psychological ones) and (ii) ‘Explanatory Attempts for Symptoms’ (symptoms influenced by cultural beliefs and conventions such as religion, alternative medical beliefs or through the enlightenment by healthcare professionals).

More recently (2010), Dr. Brennan also carried out a national online survey on Couvade Syndrome in Australia among 1439 men. He examined men’s health during and after their partner’s pregnancy. The diagnostic criterion that Brennan used for Couvade Syndrome was that men had to have experienced at least eight physical or psychological symptoms. The study found that 31% of Australian men were ‘diagnosed’ with Couvade Syndrome (compared to 25% found previously in a 2007 UK population carried out by Brennan, and 23% found in a 1982 study published by Dr. M. Lipkin and Dr. G. Lamb in the Annals of Internal Medicine). The most commonly reported symptoms were weight gain (26%), tiredness (45%), and “feeling stressed / anxious” (37%). The incidence of ‘abdominal distension’ – the so-called ‘phantom pregnancy’ was 7%.

Because Couvade Syndrome does not appear in any medical textbook, there does not appear to be any standardized and/or mainstream treatment. Anecdotally, expectant fathers suffering Couvade-type symptoms are simply told verbally that such symptoms are relatively commonplace and not to worry. Other simple interventions such as herbal remedies, relaxation techniques (e.g., meditation) and/or yoga can be employed.

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

Further reading

Brennan, A. (2010). Couvade Syndrome in Australian Men: A National Survey, 2010. Located at: http://www.abc.net.au/catalyst/fatherhood/CatalystCouvadeSurveyAustralia.pdf

Brennan, A., Ayers, S., Ahmed, H. & Marshall-Lucette, S. (2007). A critical review of the Couvade syndrome: the pregnant male. Journal of Reproductive and Infant Psychology, 25, 173- 189.

Brennan, A., Marshall-Lucette, S. Ayers, S., & Ahmed, H. (2007). A qualitative exploration of the Couvade syndrome in expectant fathers. Journal of Reproductive and Infant Psychology, 25, 18-39.

The Free Dictionary (2012). Couvade Syndrome. Located at: http://medical-dictionary.thefreedictionary.com/Couvade+Syndrome

Klein, H. (1991). Couvade syndrome: male counterpart to pregnancy. International Journal of Psychiatry Medicine, 21, 57-69.

Lipkin, M. & Lamb, G.S. (1982) The couvade syndrome: an epidemiological study. Annals of Internal Medicine, 96, 509-511.

Masoni, S., Maio, A., Trimarchi, G., de Punzio, C. & Fioretti, P. (1994). The couvade syndrome. Journal of Psychosomatic Obsteterics & Gynecology, 15, 125-131.

Storey, A.E.,  Walsh, C.J,  Quinton, R.L. & Wynne-Edwards, K.E. (2000). Hormonal Correlates of Paternal Responsiveness in new and expectant fathers. Evolution and Human Behavior, 21, 79–95

Taylor, E.B. (1865). Researches Into the Early History of Mankind and the Development of Civilization. London: John Murray.

Wikipedia (2012). Couvade Syndrome. Located at: http://en.wikipedia.org/wiki/Couvade_syndrome

Snake me up before you go-go: An unusual case of ophidianthropy

In a previous blog I examined clinical lycanthropy, a delusional psychiatric syndrome or neurological condition in which individuals believe they are transforming (or have already have transformed) into a non-human animal (often – but not necessarily – a wolf). As I noted in that blog, these identity disorders should be really be referred to as ‘therianthropy’ (as noted in Dr. Edward Podolsky’s 1953 Encyclopedia of Aberrations) or ‘zoanthropy’ but in the psychiatric literature it is ‘lycanthropy’ that tends to be used as the ‘catch-all’ name of the disorder.

A 2004 study by Dr. Petra Garlipp and her German colleagues in the journal Acta Psychiatrica Scandinavica noted the different types of animal transformation that have occurred in the psychological and psychiatric literature. Obviously human-to-wolf (or other canine) cases exist, but they appear to be in the minority. Other types include humans believing they have transformed into cats, dogs, tigers, hyenas, horses, birds, frogs and bees. Predictably, psychiatry authors claimed that the mythology surrounding human-animal transformation is controversial in Western popular culture.

Perhaps one of the most unusual cases of therianthropy was a case described by Drs. Shivanand Kattimani, Vikas Menon, Manohar Kant Srivastava and Aniruddha Mukharjee in a 2010 issue of the online journal Psychiatry Reports. They published a case report of about a 24-year old well educated woman who believed she had turned into a live snake. They published the case study because of its rarity and unique phenomenology. The case also provided difficult diagnostic problems and treatment was a challenging. The authors wrote that she:

“…presented to us with complaints that she had died 15 days before and that in her stead she had been turned into a live snake. At times she would try to bite others’ claiming that she was a snake. Her food intake and other behaviour remained as normal. We showed her photos of snakes and when she was made to face the large mirror she failed to identify herself as her real human self and described herself as snake. She described having snake skin covering her and that her entire body was that of snake except for her spirit inside. She repeatedly said that her saliva was that of snake’s and very poisonous. She would often complain of difficulty in swallowing telling that was due to snake skin being wrapped around her neck. She had protruding sharp upper incisor teeth which she could claim were snake fangs. She was distressed that others did not understand or share her conviction. She felt hopeless that nothing could make her turn into real self. She made suicidal gestures and attempted to hang herself twice on the ward and once when she was sent for short leave home. There were depressive symptoms accompanying this theme. There was no significant contributory medical history”.

The woman was subsequently treated with ten sessions of electro-convulsive therapy (ECT) along with a variety of drugs. The authors first tried fluoxetine (but there was no response), followed by risperidone, then olanzapine, trifluperazine, and carbamazepine. She remained on the psychiatric ward for nearly half a year “and during each drug trial there was some initial improvement in her symptoms but later she would return back to same conviction of her beliefs”. The ECT was administered to inhibit her severe depression and suicidal ideation. At the time the case study was written up for publication she was administered a drug combination of escitalopram and quetiapine but still had the same psychopathology as when she entered treatment (in fact the authors . In a discussion of the case, the authors noted:

“Our initial diagnosis – as she predominantly presented with depressive symptoms and suicidal attempt along with delusion of nihilism – was a severe depressive disorder with psychotic symptoms…As she additionally had a delusion of being transformed into a snake we consider the diagnosis of an acute transient psychosis. While she remained in the ward her behaviour with our other patients and personal hygiene was well preserved except for brief periods of exacerbation of her psychopathology lasting for few hours to two days wherein she would enact being a snake”

The authors also considered possible diagnoses of both dissociative disorder and schizophrenia. However, the authors decided that her “psychopathology pointed towards something more than that”. They also noted that the delusion that she had become a snake “was bizarre from the point of view of the patient’s cultural background”. Consequently (and after discussion with other psychiatric colleagues) the authors reached no consensus on the diagnosis for the disorder (except that it was clearly a psychotic illness). They did, however, propose that this “novel delusion” could be called ‘ophidanthropy’. The patient’s relatives weren’t interested in diagnosis, only that she be treated. However, this was something that the authors admitted they “were unable to provide”. In the paper’s conclusions, the authors said they planned next to try “supportive psychotherapy in combination with pharmacotherapy” but the results of these therapies have not yet (to my knowledge) been published.

Interestingly, the authors commented in passing that the woman believed she was dead but they made no other reference to this at all in their paper. To me, this looks like a possible case of Cotard’s Syndrome (where individuals hold the delusional belief that they are dead). I did note in my previous blog on clinical lycanthropy that there was an interesting case report in the psychiatric literature of a man who had both clinical lycanthropy and Cotard’s Syndrome. This case was reported by Dr. A.G. Nehad and Dr. K. Toofani in a 2005 issue of the journal Acta Psychiatrica Scandinavica. Their patient had a bipolar mood disorder, along with a psychotic delusion that he had transformed into a dog. He also suffered from the delusion that he was dead. There would certainly seem to be comparisons that can be made between these two cases.

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

Further reading

Garlipp, P., Gödecke-Koch, T., Dietrich, D.E. & Haltenhof, H (2004). Lycanthropy: Psychopathological and psychodynamic aspects. Acta Psychiatrica Scandinavica, 109, 19-22.

Kattimani, S, Menon, V., Srivastava, M.K. & Aniruddha Mukharjee, A. (2010). Ophidianthropy The case of a woman who ‘turned into a snake’. Psychiatry Reports. Located at: http://www.priory.com/psychiatry/ophidianthropy.htm

Keck, P.E., Pope, H.G., Hudson, J.I., McElroy, S.L. & Kulick, A.R. (1988). Lycanthropy: alive and well in the twentieth century. Psychological Medicine, 18, 113–20.

Larner, A.J (2010). Neurological signs: Lycanthropy. Advances in Clinical Neurocience and Rehabilitation, 10(4), 50.

Nejad, A.G. & Toofani, K. (2005). Invited comment (on ‘Co-existence of lycanthropy and Cotard’s syndrome in a single case’). Acta Psychiatrica Scandinavica, 111, 250-252.

Podolsky, E. (1953). Encyclopedia of Aberrations: A Psychiatric Handbook. New York: Philosophical Library.

Here’s looking at you: The Truman Show Delusion

Reality television shows have now became a staple of modern life. However, little is known about the effect they have on day-to-day living. Earlier this year, Joel Gold and Ian Gold published a paper in the journal Cognitive Neuropsychiatry about a new phenomenon that they coined the ‘Truman Show Delusion’ (TSD) based on (director) Peter Weir’s 1998 film that told the (fictional) story of Truman Burbank (played by Jim Carrey) whose whole life had been filmed and broadcast as real life a soap opera around the world (without his knowledge) from the day he was born. All the people around Truman were paid actors and extras.

The plot of The Truman Show revolved around Truman’s gradual awareness that there was something wrong about his life (i.e., that the world appears to revolve around him) and of his of his desire to escape the town in which he is living. Because of the high audience ratings, the show’s producers attempt to keep the show even when Truman begins to suspect there is something amiss in his life. The actors are then instructed by the show’s producers and writers to tell Truman that he is imagining these things and that he is (to all intents and purposes) mentally ill (i.e., a persecutory delusion). In their paper, Gold and Gold described the conditions as:

“…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. We describe a series of patients who presented with a delusional system according to which they were the subjects of something akin to a reality television show that was broadcasting their daily life for the entertainment of others”

Gold and Gold highlighted five short case studies of patients who had presented for treatment in their psychiatric practices. The cases ‘diagnosed’ as having the TSD are the reverse of what occurred in the film as their reported symptoms recall that of Truman, without the knowledge and awareness that their attempts to understand their situation will lead to a [Hollywood] happy ending. Interestingly, three of the cases highlighted by the authors referred to The Truman Show by name. Here is a brief summary of the five reported cases.

• Case 1 (‘Mr. A’): Mr A. claimed his life was like The Truman Show, a belief that he had held for five years without his family’s knowledge. He believed the 9/11 attacks of 9/11 were fabricated and travelled to New York to see if the Twin Towers were still standing (and if they were, it would prove that he was the star of his own show). He believed that everyone in his life were part of the conspiracy and that he had cameras implanted in his eyes (and when he was admitted to the psychiatry department he asked to speak to the ‘director’). He was diagnosed as having schizophrenia (and more specifically a chronic paranoid type versus substance-induced psychotic disorder).
• Case 2 (‘Mr. B.’): Mr B. believed he was being continuously recorded for national broadcast. He formulated a “plan to come to NYC and meet an unknown woman at the top of the Statue of Liberty. He expected [her] to release him from the control of an extended network of individuals who [were]…taping him continually…and broadcasting the tapes nationally for viewers’ enjoyment as part of a scenario similar to…The Truman Show”. He believed he “was and am the centre, the focus of attention by millions and millions of people…my [family] and everyone I knew were and are actors in a script, a charade whose entire purpose is to make me the focus of the world’s attention”. He had attempted suicide three times due to dysphoria, hopelessness, and persecutory delusions. He was diagnosed with schizoaffective disorder (bipolar type) along with both crack cocaine and marijuana dependence.
• Case 3 (‘Mr. C’): Mr. C. – a journalist – had a history of depression, and was manic and psychotic. He believed that stories – in newspapers, online, and on television – were created by his colleagues in the media for his personal amusement. He believed that those around him were paid actors, and that everything around him was fake, and that “all [his] associates are involved”. During his hospitalization, Mr. C. attempted to escape to confirm whether there were disparities between the news given on the ward and what was happening outside. He was diagnosed as having bipolar disorder with psychotic features.
• Case 4 (‘Mr. D.’): Mr D. actually worked on a reality television show and came to believe that he was the person whose life was actually being broadcast. He thought he was “a secret contestant on a reality show and believed he was being filmed. He also believed all his thoughts were being controlled by a film crew paid for by his family. He was diagnosed with bipolar disorder, had manic episodes, and a marijuana abuser.
• Case 5 (‘Mr. E’): Mr E. believed that the Secret Service was following him. He had attention deficit hyperactivity disorder and had bouts of depression. He described a “scheme” that he claimed was similar to The Truman Show. Gold and Gold reported that Mr. E. “believed that he was the master of the scheme, that it involved everyone in his life including the hospital staff, and that all these people were actors. He thought that he might be recorded while in hospital. He believed that the news was fabricated and that the radio was recorded for him…He believed that the scheme would end on Christmas Day and that he would be released then”. He was diagnosed with schizophreniform disorder versus methylphenidate-induced psychotic disorder.

Gold and Gold searched the academic and clinical literature for other similar scientific reports of patients with delusions of The Truman Show type but said there were none. However, they did cite a 2008 study by Dr. Fusar-Poli and colleagues in the British Journal of Psychiatry. They reported the case of a person who ‘‘had a sense the world was slightly unreal, as if he was the eponymous hero in the film The Truman Show [but] at no point did his conviction reach delusional intensity”. They also made reference to two news reports (one in 2007 and the other in 2009) of men who appear to have suffered from the TSD.

“In 2007, William Johns III, a psychiatrist from Florida, attempted to abscond with a child, Thorin Novenski, and subsequently attacked the child’s mother. A news report on the incident claims that ‘a friend of the psychiatrist reportedly told a judge that Johns said he had to go to New York to ‘get out of The Truman Show’.In 2009, Antony Waterlow, a Sydney man, murdered his father and sister while in a psychotic state. A news report stated that Mr Waterlow believed his family was behind a ‘world wide game’ to murder him or force him to commit suicide. A doctor who interviewed the man is reported to have said that Mr Waterlow told her in a consultation in February that he believed computers were accessing his brain through brainwaves and satellites. He said his family was screening his life on the Internet for the world to watch, akin to the film The Truman Show”.

Gold and Gold noted that their case studies gave rise to three general questions of interest: (1) How precisely should these peoples’ delusions be characterized? (2) What does the delusion contribute to the understanding of the role of culture in psychosis? (3) What does the influence of culture on delusion suggest about the cognitive processes underlying delusional belief? Obviously, watching reality television shows do not cause psychotic or delusional episodes. However, these cases appear to highlight that those with underlying illnesses (e.g., schizophrenia) who watch reality television shows may develop delusions that seem somewhat familiar. Gold and Gold concluded that cultural insights into delusions are an essential part of understanding how these phenomena operate.

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

Further reading

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, DOI:10.1080/13546805.2012.666113

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further reading

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Norse power: A brief look at Berserker rage

Ever since I was a young kid, I have used the word ‘beserk’ (to describe someone going into a mad, wild, uncontrolled and violent rage) in my day-to-day language. However, it wasn’t until I was in my teens when I bought the Gary Numan albums The Fury and Beserker that I came to realize the origin of the word.

Beserker rage is a culture-bound condition historically affecting Norsemen. The condition manifested itself among males only as an intense fury and rage (berserkergang, i.e., “going beserk”) and mostly occurred in battle situations (but could also occur when they were engaged in labour-intensive work). Dating back as far as the ninth century, the berserker Norse Warriors were alleged to be able to perform almost seemingly impossible super-human feats of strength. Nowadays, the word ‘berserker’ refers to anyone that fearlessly fights with a disregard to their own lives. Similar conditions have been noted in other cultures. For instance, the Irishman Cúchulainn (“Culann’s Hound”) was recorded as displaying ‘battle frenzy’ and ‘foaming at the mouth’ akin to berserkers in texts such as The Tain. The Malay phenomenon of ‘running amok’ (i.e., running mad with rage) also appears to bear a close resemblance to berserkers.

Those displaying beserker behaviour were also said to experience a specific set of symptoms prior to the rage (i.e., beginning with shivering and chattering of their teeth, followed by a swelling and changing of colour in the face as they literally became ‘hot-headed’. The final stage was full-blown rage and fury accompanied by noisy grunts and howls. They would then just indiscriminately injure, maim and kill anything in their path. This would be followed by one or two days of feebleness, along with a dulling of the mind. The condition of berserkergang was described in the thirteenth century by Icelandic poet Snorri Sturluson:

“[Odin’s] men rushed forwards without armour, were as mad as dogs or wolves, bit their shields, and were strong as bears or wild oxen, and killed people at a blow, but neither fire nor iron told upon them. This was called Berserkergang”.

The ravenous self-induced rage before battle commenced enabled the Norsemen to indiscriminately ‘loot, plunder and kill’. 
A recent book about the Vikings claimed that some battle chiefs held their berserkers “in reserve” during a battle. The berserkers were only sent into fight if one section began to weaken. An article on berserkers in the Journal of World History by Dr. M. Speidel noted that Norse berserkers were very effective killers, but could not stop killing at will. Apparently, their berserker state was only turned off once all members of the opposition were dead. László Kürti, in a 2004 encyclopedia entry on shamanism claimed that berserker is a regional form of present-day shamanism that utilizes archaic Nordic techniques – particularly the ability to go into a trance-like state.

Various theories about the causes of the condition have been speculated. Some have alleged that psychoactive drugs (such as hallucinogenic agaric mushrooms or copious alcohol drinking) were used. Some botanists claim that berserker behavior can be caused by the ingestion of the plant bog myrtle, one of the main spices in Scandinavian alcoholic beverages. Other theories speculate either pre-existing genetic and/or medical conditions or pre-existing psychological disorders (e.g., mental illness, manic depression [i.e., bipolar disorder], epilepsy). Some have even speculated that the fury may just be a consequence of post-traumatic stress. For instance, clinical psychiatrist Dr. Jonathan Shay wrote in his 1994 book Achilles in Vietnam:

“If a soldier survives the berserk state, it imparts emotional deadness and vulnerability to explosive rage to his psychology and permanent hyperarousal to his physiology –  hallmarks of post-traumatic stress disorder in combat veterans. My clinical experience with Vietnam combat veterans prompts me to place the berserk state at the heart of their most severe psychological and psychophysiological injuries”

Professor Jesse L. Byock claimed in a 1995 issue of Scientific American, that berserker rage could perhaps have been a symptom of Paget’s Disease (i.e., uncontrolled skull bone growth that often causes painful pressure in the head). However, there doesn’t seem to be any conclusive evidence of this.

Other more esoteric theories surround spiritual and/or supernatural beliefs. For instance, some scholars have claimed that the Vikings believed in spirit possession and that berserkers were possessed by the animal spirits of wolves and/or bears. According to some theorists, berserkers learned to cultivate the ability to allow animal spirits to take over their body during a fight (an example of animal totemism) that also involved drinking the blood of the animal that they wished to be possessed by.

Back in 1987, Dr. Armando Simon published a paper in the journal Psychological Reports and argued that berserker rage (or as he termed it ‘Blind Rage Syndrome’) should be incorporated into the Diagnostic and Statistical Manual of Mental Disorders. Dr. Simon characterized the condition as (i) violent overreaction to physical, verbal, or visual insult, (ii) amnesia during the actual period of violence, (iii) abnormally great strength, and (iv) specifically target oriented violence. Some case studies are presented and a parallel is made with the Viking Berserkers of the Middle Ages. Dr. Simon also claimed that the condition had typically been diagnosed as part of other violent disorders (such as intermittent explosive disorder). However, it looks unlikely that berserkers will be making a separate entry into the DSM anytime soon.

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

Further reading

Armando, S. (1987) the berserker/blind rage syndrome as a potentially new diagnostic category for the DSM-III. Psychological Reports, 60, 131-135.

Kürti, L. (2004). Shamanism – Neo (Eastern Europe). Located at: http://publikacio.uni-miskolc.hu/data/ME-PUB-31198/Kurti_Neo_shamanism_2004.pdf.

Nationmaster (2012). Berserker. Located at: http://www.statemaster.com/encyclopedia/Berserker

Shay, J. (1994). Achilles in Vietnam. New York: Scribner.

Simon, A. (1987). The berserker/blind rage syndrome as a potentially new diagnostic category for the DSM-III. Psychological Reports, 60, 131-135.

Speidel, M. (2002). Berserks: A history of Indo-European ‘mad warriors’. Journal of World History 13, 253-290.

Wikipedia (2012). Berserker. Located at: http://en.wikipedia.org/wiki/Berserker

Barking mad? A brief overview of clinical lycanthropy

With the recent success of the ‘Twilight’ series of films, lycanthropy has once again come to the fore in popular culture. Lycanthropy is usually defined as a supernatural behaviour in which a person believes they have changed into a wolf (i.e., a shape-shifting ‘werewolf’). However, as a psychiatric syndrome, ‘clinical lycanthropy’ is similar to a psychosis and involves individuals who have delusional behaviour and believe they are transforming (or have already have transformed) into a non-human animal (often – but not necessarily – a wolf). Technically, this should be referred to as ‘therianthropy’ or ‘zoanthropy’ but in the psychiatric literature it is ‘lycanthropy’ that tends to be used as the ‘catch-all’ name of the disorder. These changes (understandably) only happen in the mind of the affected individual. Although there is a clear similarity to various psychotic behaviours, there do not appear to be any specific diagnosis of mental or neurological illness associated with the resulting behaviour. Some authors have also described lycanthropy as an identity disorder.

The delusional belief in metamorphosis to animal form is not new and back in the 18^th century was termed ‘Insania Zooanthropica’. A reference as recent as 1992 by Dr. W.M. Davis and colleagues – in the Canadian Medical Association Journal – referred to it as ‘lycomania’. Those individuals affected with clinical lycanthropy typically have other conditions such as clinical depression, mood disorders (e.g., bipolar disorder), and schizophrenia. A 2004 study published describing clinical lycanthropy in over 30 cases by Dr. Petra Garlipp (Hannover Medical School Germany) and colleagues in the journal Acta Psychiatrica Scandinavica proposed some diagnostic criteria (based on past and/or current behaviour) by which the disorder can be diagnosed:

• Individuals report in “a moment of clarity” or retrospectively that they sometimes feel and/or have felt like an animal.
• Individuals behave in a way that resembles animal behaviour (creeping, barking, etc.).
• Individuals voice their beliefs that they are animals.

The review paper by Dr. Garlipp and her colleagues also noted the different types of animal transformation that have occurred in the psychological and psychiatric literature. Obviously human-to-wolf (or other canine) cases exist, but they appear to be in the minority. Other types include humans believing they have transformed into cats, tigers, hyenas, horses, birds, frogs and bees. There are also cases of “multiple serial lycanthropy” where a range of animal transformations is reported within one individual. For instance, one case reported in a 1989 issue of the journal Psychopathology described a man who believed he had transformed first into a dog, and then into a horse, and a cat. There is some evidence that people who report lycanthropic experiences really do perceive the feelings as real. Neuroimaging studies (again published in the journal Psychopathology) have shown that the areas of the brain (e.g., cerebellum) concerned with body shape and body image perception are activated in such individuals.

There also appear to be unusual variants of lycanthropy in the psychological literature. In rare cases, individuals may also believe that other people around them have changed into animals. This has been called ‘lycanthropic intermetamorphosis’ (by Dr. H.F. Moselhy, in a 1999 issue of Psychopathology) and ‘lycanthropy spectrum’ (by Dr. A.G. Nejad in a 2007 issue of Acta Psychiatrica Scandinavica). A study published in a 2009 issue of the journal Addiction and Health by Dr. Mansoureh Nasirian and colleagues (all at the Kerman University of medical Science, Iran) described the symptoms of lycanthropy in other individuals appearing after an unemployed 28-year old man had taken the drug ecstasy. The man believed that three of his close relatives had changed into donkey, boar, and horse. The authors argued that ecstasy drug can induce paranoid psychosis similar to schizophrenia, and that in their lycanthropy case, the ecstasy appeared to have had a role in the man’s underlying susceptibility to schizophrenia.

There is also an interesting case report in the psychiatric literature of a man who had both clinical lycanthropy and Cotard’s Syndrome (where individuals hold the delusional belief that they are dead – figuratively or literally – and do not exist) that I examined in a previous blog. He also had zoophilic tendencies. This particular case was reported by Dr. A.G. Nehad and Dr. K. Toofani in a 2005 issue of the journal Acta Psychiatrica Scandinavica. Their patient had a bipolar mood disorder, along with a psychotic delusion that he had transformed into a dog. Confusingly, he also suffered from the delusion that he was dead. The authors also reported that he was restless and had a serious sense of guilt about his previous sexual contact with sheep. As far as the authors are aware, this is the only case of its kind. In this case, they believed that the man’s zoophilic orientation producing a sense of guilt were the most important factors causing his delusions.

Despite the rareness of the disorder, Dr. Petra Garlipp – in an invited comment on the paper by Nehad and Toofani – thinks it is more common than is reported. She concludes:

“Lycanthropy is a delusional symptom rarely described in the literature but probably seen a lot more often in clinical psychiatry. Reasons for this discrepancy may be the often short duration of the symptomatology, the lack of interpretation as lycanthropy if the metamorphosis is not verbally uttered by the patient and just the behaviour is shown”.

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

Further reading

Davis, W.M. Wellwuff, H.G., Garew, L. & Kydd, O.U. (1992). Psychopharmocology of lycanthropy. Canadian Medical Association Journal, 146, 1191-1197.

Dening, T.R. & West, A. (1989). Multiple serial lycanthropy. A case report. Psychopathology, 22, 344–347.

Fahy, T.A. (1989). Lycanthropy: A review. Journal of Royal Society of Medicine, 82, 37-39.

Garlipp, P. (2005). Invited comment (on ‘Co-existence of lycanthropy and Cotard’s syndrome in a single case’). Acta Psychiatrica Scandinavica, 111, 252.

Garlipp, P., Gödecke-Koch, T., Dietrich, D.E. & Haltenhof, H (2004). Lycanthropy: Psychopathological and psychodynamic aspects. Acta Psychiatrica Scandinavica, 109, 19-22.

Keck, P.E., Pope, H.G., Hudson, J.I., McElroy, S.L. & Kulick, A.R. (1988). Lycanthropy: alive and well in the twentieth century. Psychological Medicine, 18, 113–120.

Larner, A.J (2010). Neurological signs: Lycanthropy. Advances in Clinical Neurocience and Rehabilitation, 10(4), 50.

Moselhy, H.F. (1999). Lycanthropy: New evidence of its origin. Psychopathology, 32, 173–176.

Nasirian M., Banazadeh, N. & Kheradmand, A. (2009). Rare variant of lycanthropy and ecstasy. Addiction and Health, 1(1), 53-56.

Nejad, A.G. (2007). Belief in transforming another person into a wolf: Could it be a variant of lycanthropy? Acta Psychiatrica Scandinavica, 115, 159-161.

Nejad, A.G. & Toofani, K. (2005). Invited comment (on ‘Co-existence of lycanthropy and Cotard’s syndrome in a single case’). Acta Psychiatrica Scandinavica, 111, 250-252.

High interest: Is jenkem hokum?

While I was researching a previous blog on “cremainlining” (i.e., people who allegedly snort the ashes of dead people), I came across a number of press stories (all from the end of 2007) that American teenagers were allegedly using ‘jenkem’ and that it was becoming an epidemic in terms of its usage. Since the 2007 reports surfaced in the US, many further press reports and stories have questioned whether there is any evidence of jenkem use at all.

For those who have no idea what I am talking about, jenkum is a street drug (allegedly an auditory and visual hallucinatory inhalant) that is made from fermented human faeces and urine and according to users is more potent than cannabis and (according to news reports) gives “a powerful high” and has dissociation properties. The effects are alleged to last for about an hour, and it is sometimes known by the name ‘butthash’. Emma Guest describes jenkem as:

“Fermented human sewage, scraped from pipes and stored in plastic bags for a week or so, until it gives off numbing, intoxicating fumes” (from her 2003 book Children of AIDS: Africa’s Orphan Crisis)

Reports of its use first surfaced during the 1990s when news stories (including one by the BBC) started appearing about its use by Zambian children and teenagers living in Lusaka because it cost next to nothing to make. The correspondent who covered the story for the BBC (Ishbel Matheson) witnessed the practice first-hand:

“At the Lusaka sewage ponds, two teenage boys plunge their hands into the dark brown sludge, gathering up fistfuls and stuffing it into small plastic bottles. They tap the bottles on the ground, taking care to leave enough room for methane to form at the top. A sour smell rises in the hot sun, but the boys seem oblivious to the stench and the foul nature of their task. They are manufacturing ‘Jenkem’, a disgusting, noxious mixture made from fermented sewage. It is cheap, potent and very popular among the thousands of street-children in Lusaka. When they cannot afford glue or are too scared to steal petrol, these youngsters turn to Jenkem as a way of getting high… Nobody knows exactly where the idea for making Jenkem came from, but it has been used by street-children in Lusaka for at least two years. Nason Banda of the Drug Enforcement Agency is not proud when he says that it is unique to Zambia. He shudders when he sees the boys at the sewage ponds, scavenging for faecal matter to make Jenkem”.

Jenkem derives its name from an African brand of glue named ‘Genkum’ which became the generic name for all types of glue used by African teenage glue sniffers. According to an interview conducted by Jamie Pietras in Salon magazine, Fumito Ichinose (an American expert on anesthesia was quoted as saying that “the inhalation of gases like those produced from jenkem could result in hypoxia, a lack of oxygen flow to the body that could be alternately euphoric and physically dangerous”. Pietras also reported that:

“Psychedelic researchers are unconvinced that huffing fecal fumes ever caught on in the U.S. ‘It is potentially believable to me that a handful of extremely experimental people have tried this, but it is also quite easy for me to believe that no one in the U.S. has actually produced and inhaled sewage gas of their own,’ says Earth Erowid, co-creator of Erowid.com, a repository of documented narcotic experiences, in an e-mail. The communications director for the Multidisciplinary Association for Psychedelic Studies, Jag Davies, is equally skeptical. Davies says no one at MAPS, which supports research into the medical use of hallucinogens, has heard of jenkem use and certainly not jenkem research in the United States”.

An article on jenkum in Wikipedia reported that:

“In 2002, Project Concern International Zambia and Fountain of Hope released a report entitled ‘Rapid Assessment of Street Children In Lusaka’ where jenkem is listed as the third most popular drug among Lusaka’s street children, following Dagga (cannabis) and “glue and Dagga” but ahead of ‘Ballan’ (uncured tobacco) and petrol”.

It wasn’t until September 2007 that alleged use of jenkem by American adolescents first emerged following a bulletin about jenkem use issued by Corporal Disarro at Collier County’s Sheriff’s Department in Florida. The bulletin was instigated following an email to Disarro from a concerned parent regarding “a new drug called Jenkem”. The parent told Disarro that her child had learned about Jenkem through various conversations with several students at Palmetto Ridge High school. Disarro then researched the existence of the drug including a report on the TOTSE website.

However, the bulletin distributed across many US states was based on information from the dubious TOTSE website, and later admitted as a hoax by the person who posted the original article. (The TOTSE – Temple of the Screaming Electron – website was based in San Francisco and published on controversial and/or unusual subjects). However, the story spread and was reported by many major US news outlets including the Washington Post newspaper and the Fox News television channel. The story eventually spread to other countries including national television coverage in Australia.

From all my own reading on the topic it would appear that some American teenagers have tried jenkem (most likely as a result of hearing about it on the news) and even video recorded the experience. There are certainly videos on YouTube of jenkem being made and used. However, there doesn’t appear to be any evidence for widespread jenkem use except perhaps in Lusaka where the story originated.

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

Further reading

Guest, E. (2003). Children of AIDS: Africa’s Orphan Crisis. London: Pluto Press.

Matheson, I. (1999). Children high on sewage. BBC News, July 30. Located at: http://news.bbc.co.uk/1/hi/world/africa/406067.stm

Mikkelson, B. & Mikkelson, D. (2011). Jenkum. Snopes.com, July 28. Located at: http://www.snopes.com/crime/warnings/jenkem.asp

Morgan, S. (2007). Drug Scare: Kids in Florida are Getting High by Sniffing Feces. Stop The Drug War, November 5. Located at: http://stopthedrugwar.org/speakeasy/2007/nov/05/drug_scare_kids_florida_are_gett

Pietras, J. (2007). Smoke this! Salon, November 9. Located at: http://www.salon.com/2007/11/09/jenkem/

Wikipedia (2012). Jenkem. Located at: http://en.wikipedia.org/wiki/Jenkem

Bump start: An overview of delusions of pregnancy

Delusions of pregnancy are relatively rare and have been reported in both males and females (although it is more common in men). The first documented case of delusional pregnancy was reported by Esquirol at the turn of the nineteenth century. Among women it can occur right across the age range including virginal young women and post-menopausal women. It has been associated with a variety of different disorders including general delusional disorders, organic brain syndromes (e.g., senile dementia), mental retardation, schizophrenia, schizoaffective disorder, epilepsy, metabolic syndrome, neuroendocrine abnormalities, sexual identity confusion, cerebral syphilis (following encephalitis), polydypsia, and drug-induced lactation.

A 1996 paper by Dr. Shabari and Dr. G.K. Vankar published in the Indian Journal of Psychiatry, made the important distinction between delusions of pregnancy and four other related – but psychologically different – disorders. Exactly the same observations were made in a 2009 issue of the European Journal of Psychiatry by a Hungarian team led by Dr. Maria Simon. The four pregnancy-related disorders were:

• Pseudocyesis (whereby false ‘pregnancy’ occurs in either women or men with marked bodily signs of pregnancy but where the individuals are not actually pregnant).
• Couvade Syndrome (whereby the male partners of pregnant women experience empathetic pregnancy-like symptoms including loss of appetite, morning sickness, constipation, etc. The male knows he is not pregnant)
• Malingering (whereby individuals – male or female – claims to be pregnant knowing that they are not).
• Pseudo-pregnancy (whereby a somatic state resembling pregnancy occurs in women that is triggered by organic factors, such as ovarian tumours causing endocrinal changes leading to pregnancy-like symptoms).

In a 1994 issue of the British Journal of Psychiatry, Dr. A. Michael and his colleagues reported five cases of pregnancy delusion (three females and two males) that included one case where the delusion had lasted 20 years. Other case reports by Dr. K.N. Chengappa and colleagues – also in the British Journal of Psychiatry – found that he same individuals can have multiple delusional pregnancies over long periods as well as believing they are having multiple births. There doesn’t seem to be any common characteristics among those with pregnancy delusions as demonstrated by these four reports from various cases reported in psychiatric journals.

• Report 1: A 51-year old American man turned up to a hospital insisting he was pregnant. The man was said to have no organic cerebral pathology but had a 20-year history of chronic delusional disorder. He even inserted a knife into his anus to facilitate delivery of the “baby”. The delusion of pregnancy subsided over a four-month period following a course of chlorpromazine (reported in the American Journal of Psychiatry, 1991).
• Report 2: Delusions of pregnancy were reported in five women aged over 64 years. All five women were reported as having major depressive episodes with mood-congruent delusions. The symptoms were discussed in relation to other delusions such as Cotard’s Syndrome (reported in the International Journal of Geriatric Psychiatry, 1995).
• Report 3: While on chlorpromazine medication, a psychotic 15-year old female developed a delusion of pregnancy. The delusions were initiated because the girl developed galactorrhea (breast milk production) – one of the side effects of taking high doses of chlorpromazine. It was concluded that the incidence of pregnancy delusions may be higher among female institutionalized patients treated with chlorpromazine (reported in the American Journal of Psychiatry, 1971).
• Report 4: A 43-year old man presented with a persistent pregnancy delusion. The man suffered from chronic schizophrenia and was described as coming from a background of poor sexual adjustment (reported in the journal Psychopathology, 1995).

A 2002 study by Dr. D.S. Rosch and his associates published in the International Journal of Psychiatry in Medicine was the first to utilize a standardized mental disorder assessment tool (the Brief Psychiatric Rating Scale) to compare a group of 11 women with delusional pregnancy with a group of 11 female controls. Compared to the control group, women with pregnancy delusions had significantly higher levels of hostility, higher rates of prescribed poly-pharmacy, and a trend toward higher antipsychotic medication dosages. The authors reported that their findings may be suggestive of greater resistance to treatment in women with pregnancy delusions.

A more recent 2008 study published in the journal Psychosomatics by Dr. N. Ahuja and colleagues looked at the association between pregnancy delusions and antipsychotic-induced hyperprolactinemia. Among 12 patients taking such medication, six of them had erroneous ideas of being pregnant (four delusional and two non-delusional).

Most of the literature comprises case studies and therefore the literature base is limited by relatively few cases and by those who present for treatment. As Dr. Maria Simon and her colleagues concluded in their paper in the European Journal of Psychiatry:

“Case reports usually reveal demographic characteristics, describe response to treatment, and/ or suggest etiology. Patients with delusional pregnancy have been reported to be more hostile and treatment resistant compared with matched controls. Possible etiological factors in delusion of pregnancy are typically limited to neurophysiologic, endocrine and traditional psychodynamic factors. Given the growing evidence of cognitive and affective models of delusion formation, an integrated, individualized model of delusion of pregnancy can advantageously contextualize the phenomenology and course of the illness”.

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

Further reading

Adityanjee, A.M. (1995). Delusion of pregnancy in males: A case report and literature review. Psychopathology, 28, 307-311.

Ahuja, N., Moorhead, S., Lloyd, A.J. & Cole, A.J. (2008). Antipsychotic-induced hyperprolactinemia and delusion of pregnancy. Psychosomatics, 49, 163-167.

Ali, J.A., Desai, K.D. & Ali, L.J. (2003). Delusions of pregnancy associated with increased prolactin concentrations produced by antipsychotic treatment.International Journal of Neuropsychopharmacology, 6, 111-115

Bitton, G., Thibaut, F. & Lefevre-Lesage, I. (1991). Delusions of pregnancy in a man. American Journal of Psychiatry, 148, 811-812.

Camus,^, V., Schmitt, L., Foulon, C., De Mendonça Lima, C.A. Wertheimer, J. (1995).Pregnancy delusions in elderly depressed women: A clinical feature of Cotard’s syndrome? International Journal of Geriatric Psychiatry, 10, 1071-1073.

Chengappa, K.N., Steigard, S., Brar, J.S., & Keshavan, M.S. (1989) Delusion of pregnancy in men. British Journal of Psychiatry 155, 422-423

Cramer, B. (1971). Delusion of pregnancy in a girl with drug-induced lactation. American Journal of Psychiatry, 127, 960-963.

Dutta, S. & Vankar, G.K. (1996). Delusions of pregnancy – A report of four cases. Indian Journal of Psychiatry, 38, 254-225.

Manjunatha, N. & Saddichha, S. (2009). Delusion of pregnancy associated with antipsychotic induced metabolic syndrome. World Journal of Biological Psychiatry, 10, 669-670.

Michael A., Joseph A., Pallen A. (1994) Delusions of pregnancy. British Journal of Psychiatry, 164, 224-246.

Rosch, D.S., Sajatovic, M. & Sivec H. (2002). Behavioral characteristics in delusional pregnancy: A matched control group study. International Journal of Psychiatry in Medicine, 32, 295-303.

Simon, M., Vörös, V., Herold, R., Fekete, S., Tényi, T. (2009). Delusions of pregnancy with post-partum onset: An integrated, individualized view. European Journal of Psychiatry, 23, 234-242.

Tényi, T., Herold, R., Fekete, S., Kovács, A., & Trixler, M. (2001). Coexistence of delusions of pregnancy and infestation in a male, Psychopathology, 34, 215-216.