Category Archives: Eating disorders
In a previous blog I looked at sitophilia, a sexual paraphilia in which individuals have an erotic attraction to (and derive sexual arousal from) food. One of the strangest sitophile stories I have read concerns the case of the ‘Swiss Cheese Pervert’. In the run up to Christmas 2013, a chubby man estimated to be in his 40s was driving around the Mayfair district of Philadelphia (USA) and exposing his genitals to a number of women while seated in his Sedan. However, this was no ordinary case of exhibitionism. As the Fortean Times reported:
“He would then dangle a large slice of Swiss cheese over his penis and offers to pay the women to perform sexual acts on him using the snack. At least two other women received messages on [the] OKCupid [online dating website] they believe were from the same man, describing how being unpopular with women drove him to have sex with cheese. He offered to pay $50 for a woman to pleasure him with a slice. The city’s police suspect 41-year-old Chris Pagano, since he was arrested in 2006 and 2009 for allegedly propositioning women with Swiss cheese on the streets of Norristown, Philadelphia. Pagano claimed that the latest incidents had nothing to do with him – but the picture he used on Facebook was the same as the one on the OKCupid profile message sent to a woman asking her to indulge his cheese craving”.
Pagano’s previous arrests were well documented in the local Philadelphia press and one journalist (Victor Fiorello) has written a number of stories about Pagano’s sexual exploits. In one of his stories he obtained the court documents in relation to the 2006 and 2009 arrests and one extract (with the woman’s name removed to protect her identity) read that:
“[The woman] told police that at approximately 0030 hours she was walking home from a store the male approached her from behind and asked her a question. The male removed a large block of cheese from his pocket and told [the woman] that he would pay her $20 to rub the Swiss cheese on his penis. [The woman] became alarmed and fled on foot toward her residence. The male offered [the woman] more money as she fled the area. [The woman] described the male as white, balding, and weighing over 300 pounds”
Following the late 2013 reports in the local press, one woman (Gabby Chest) telephoned the police saying that she had got an email on the OKCupid website from a “really strange guy” fitting the description of Pagano and who in his message wrote that he was “looking for someone to perform masturbation on him with cheese”. In the online message to Ms. Chest, the man admitted that he had great difficulty in initiating relationships with women because of his weight problem. This (he claimed) led to his cheese fetish and helped him to deal with his sexual urges. The whole message was reprinted on the PhillyMag website and I have reprinted it verbatim as I think it provides a good insight into the behaviour:
“Hello, my name is Chris. I am sure you are seeking a relationship, and I am sort of seeking the same, well sort of. You see I am currently content with my life. I enjoy meeting new people and making friends, but I also enjoy looking for women who are just looking for fun, opportunities, and or sex. I am kind of hoping you may be one of those women, who are open to certain activities of a suggestive nature. I realize talking and or requesting anything sexual with a someone you don’t know can be a turn off for most, but would you be interested in getting to know me, and perhaps being involved in a sexual encounter together? I know it’s a bit much to take in, since you really don’t know me. Still I am open to get to know you at first before anything would happen. I want to be up-front with you and tell you what exactly I am looking for. This way you have an idea of what I am into. You see it’s not sex in the traditional sense, it’s more a fetish. Don’t get me wrong I do enjoy traditional sex, but I grown to prefer this more. This fetish is a Sitophilia type fetish. I will give you a short explanation that lead me to discover why I like this type of fetish.
You see, when I was young and even now I seemed to be judged on my looks and not on my personality. So finding women and starting relationships was harder for me then most. Couple that with a strong sex drive, and you get the picture. So I developed this fetish to help me deal with my sexual urges. I found that women tend to like dairy products, and settled on cheese to represent the girl. Thus I started having sex with cheese. I like to use Swiss cheese and would wrap slices of the cheese around penis, then masturbate. Now tho [sic], after finding several girls to do it for me, I prefer having girls do it for me, instead of myself. Still I suppose I was lucky in finding those women, and our relationships did not last long, since our relationship based more on my fetish and me helping them out money wise. When they became comfortable again, we stayed friends, but they seemed to move on with their lives or I moved on because of the drama that sometimes followed some of them. The other problem I encounter is that women tend to be more freaked out over my fetish, then they would be over other questionable activities that are far more disgusting then mine. I don’t understand why using cheese in the way I use it is so disturbing to women, the ones who have done my fetish for me say it’s quite vanilla compared to so things they have encountered, and say I am quite harmless given my kind personality. So my request is, is there any way you would be willing to strike up an arraignment with me to do my fetish for me, if of course you would be open to this sort of activity?
Lastly if I have offended you, I am sorry as it was not my intention to do so. I just hope my fetish with cheese does not disturb you in any way, sorry if it has. Also when I mention arrangement, please don’t think it just has to be money either, I know you are not a prostitute, in fact I don’t want women like that at all. It can be anything you feel is a fair trade. Please if you could please let me know if you might be interested or not, and what you think of my request, I would appreciate it, thanks”.
In another online message, it is alleged that he said: “I am lucky I never became a rapist”. This latter admission suggesting that his cheese infatuation was a less palatable alternative to his cheese infatuation. In an email on the OKCupid website, he wrote to another woman and added:
“I tried many different kinds of cheese, like American, Provolone, chez whiz, jack, and cheddar, but settled on Swiss as the best…because of its eye patterns, texture, and the way it feels against my penis. When I was younger I had far more stamina for cheese sex. I was able to wrap and wear a good 1½ pounds of Swiss cheese against my penis, and wear it for hours at a time before I would climax…One last note, I do not like cheese, except for mozzarella, and that is the one cheese I have never used on myself. So no I do not eat the cheese after I am done using it for pleasure, it is discarded. I am always asked that question”.
I found the online message sent to Ms. Chest of great psychological interest. Pagano obviously knew that his preferred sexual behaviour was sitophilia and that he himself conceptualized his own behaviour as fetishistic. He also provided what I believe to be a plausible explanation as to how cheese became a symbolic female substitute for sex. Using cheese in his early masturbatory experiences would almost certainly created an associative pairing between sex and cheese (to the point where cheese on its own may have caused a classically conditioned response resulting in sexual arousal). Pagano’s own realistic assessment of his sexual attractiveness appears to have led to sexual displacement in which cheese represented an outlet for his sexual urges and desires. He was fully aware that his desires would seem strange to most people and that he was prepared to pay for the activity if that helped women participate. From the newspaper reports I read, it would appear that the criminal exhibitionism (i.e., flashing his genitalia at women he approached in his car) was peripheral to his real desire of soliciting women to engage in ‘cheesy’ sex.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.
Daily Mail (2014). ‘Swiss Cheese Pervert’ terrorizes Philadelphia asking women to perform sexual acts on him using a slice of fromage. Daily Mail. January 13. Located at: http://www.dailymail.co.uk/news/article-2538687/Swiss-Cheese-Pervert-terrorizing-Philadelphia.html
Fiorello, V. (2014). Is this guy the Swiss Cheese Pervert? PhillyMag, January 11. Located at: www.phillymag.com/news/2014/01/11/norristowns-swiss-cheese-pervert/
Fiorello, V. (2014). Here are mugshots of alleged Swiss Cheese Pervert Chris Pagano. PhillyMag, January 11. Located at: http://www.phillymag.com/news/2014/01/13/mugshots-swiss-cheese-pervert-chris-pagano/
Fortean Times (2014). Please cheese me…Fortean Times, March 1, p.10
Displeasures of the flesh: A brief look at anthropophagolagnia and paraphilic behaviour in serial killers
In previous blogs I have examined the psychology of sexual cannibalism and erotophonophilia (aka ‘lust murder’) as well as an article that I wrote on serial killers that collect their victims’ body parts as ‘trophies’. One very rare sub-type of both sexual cannibalism and erotophonophilia is anthropophagolagnia. This particular type of sexual paraphilia has been defined by Dr Anil Aggrawal as the paraphilia of “rape with cannibalism” and by the Right Diagnosis website as “sexual urges, preferences or fantasies involving raping and then cannibalizing the victim”.
The Listaholic website goes as far to say that anthropophagolagnia is one of the ten “most bizarre sexual fetishes on earth” claiming that serial killer is the “poster boy” for these “twisted” individuals. Other serial killers that might be classed as anthropophagolagniacs include Albert Fish, Peter Kirsten, Ottis Toole and Ed Gein. However, there also appear to be cases of what I would call ‘systematic anthropophagolagnia’ if the extract I found online is true:
“While it is easy to dismiss one case as stemming from some sort of neurological aberrations in the participants, we also see sexualized cannibalism in modern day Africa. In the early 2000s in Congo, rape and cannibalism were reported to coincide sporadically across the region. The claims are backed by a UN investigation into the phenomena…Rebels would go into villages and rape the women and children, then dismember them alive while eating their flesh. There are many reports of family members being forced to eat the flesh of other murdered family members after being raped…The men committing these atrocities do not have any neurological aberrations, they simply have the power to exercise this behavior. While cannibalism has been practiced in Africa as part of spiritual traditions for centuries, sadistic sexualized torture is not part of that tradition. So why add it in? Presumably the rebels didn’t all happen to be born child rapists either, yet raping children is part of their terror campaign and they must be able to achieve an erection to carry out the task, and so it must be assumed they learned to like it”.
Last year, I also read about 40-year old preacher Stephen Tari, the leader of a 6,000-strong cannibal rape cult in Papua New Guinea. He was in prison following his conviction for a brutal rape but escaped (only to be killed by people from his village in retaliation for the cannibalistic rape murders he had committed). As a report in The Independent noted:
“[Tari] had previously been accused of raping, murdering and eating three girls in front of their traumatised mothers…The charismatic cult leader, who wore white robes and is said to have regularly drunk the blood of his ‘flower girls’, quickly returned to his home village of Gal after [a prison] escape, but could only manage six months before killing yet again…It has not yet been established if the murdered woman was killed as part of a blood sacrifice, but it is considered likely as Tari was said to have been attempting to resurrect his cult following the spell in prison”.
Dr. Eric Hickey (in his book Serial Murderers and Their Victims) notes that paraphilic behaviour is very common among those that commit sexual crimes (and that more than one is often present) but that the two activities (sex offending and paraphilias) may be two independent constructs and that one does not necessarily affect the other. In fact he notes that:
“Rather than paraphilia being caused by sexual pathology, they may be better understood as one of many forms of general social deviance…For the male serial killer, the paraphilia engaged in usually has escalated from softer forms to those that are considered not only criminal but violent as well. They range from unusual to incredibly bizarre and disgusting. As paraphilia develop, men affected by them often engage in several over a period of time. Most men who engage in paraphilia often exhibit three or four different forms, some of them simultaneously. For those with violent tendencies, soft paraphilia can quickly lead to experimentation with hardcore paraphilia that often involves the harming of others in sexual ways. For example, some paraphilic offenders prefer to stalk and sexually assault their victims in stores and other public places without getting caught. The thrill of hunting an unsuspecting victim contributes to sexually arousing the offender”.
Hickey asserts that anthropophagolagnia is one of the so-called ‘attack paraphilias’ (as opposed to the ‘preparatory paraphilias’). Attack paraphilias are described by Hickey as being sexually violent (towards other individuals including children in extreme circumstances). Preparatory paraphilias are defined by Hickey as those “that have been found as part of the lust killer’s sexual fantasies and activities” (including those that display anthropophagolagnia). However, Hickey notes that individuals that engage in preparatory paraphilias do not necessarily go on to become serial killers. He then goes on to say:
“The process of sexual fantasy development may include stealing items from victims. Burglary, although generally considered to be a property crime, also is sometimes a property crime for sexual purposes. Stealing underwear, toiletries, hair clippings, photographs, and other personal items provides the offender with souvenirs for him to fantasize over”.
Some of the examples Hickey cites are both revealing and psychologically interesting:
“One offender noted how he would climax each time he entered a victim’s home through a window. The thought of being alone with people sleeping in the house had become deeply eroticized. Another offender likes to break into homes and watch victims sleep. He eventually will touch the victim and will only leave when she begins to scream. He ‘began’ his sexual acting out as a voyeur. This paraphilic process was also examined by Purcell and Arrigo (2001), who note that the process consists of mutually interactive elements: paraphilic stimuli and fantasy; orgasmic conditioning process; and facilitators (drugs, alcohol, and pornography). The probability of the offender harming a victim is extremely high given the progressive nature of his sexual fantasies”.
Along with anthropophagolagnia, other ‘attack paraphilias’ that have been associated with serial killers include amokoscisia (sexual arousal or sexual frenzy from a desire to slash or mutilate other individuals [typically women]), anophelorastia (sexual arousal from defiling or ravaging another individual), biastophilia (sexual arousal from violently raping other individuals; also called raptophilia), dippoldism (sexual arousal from abusing children, typically in the form of spanking and corporal punishment), necrophilia (sexual arousal from having sex with acts with dead individuals), paedophilia (sexual arousal from having sex with minors typically via manipulation and grooming), and sexual sadism (empowerment and sexual arousal derived from inflicting pain and/or injuring other individuals).
The ‘preparatory paraphilias’ that typically precede serial killing and attack paraphilias such as anthropophagolagnia include agonophilia (sexual arousal caused by a sexual partner pretending to struggle), altocalciphilia (sexual arousal from high-heeled shoes), autonecrophilia (sexual arousal by imagining oneself as a dead person), exhibitionism (exposing genitals to inappropriate and/or non-consenting people for sexual arousal), frottage (sexual arousal from rubbing up against the body against a sexual partner or object), gerontophilia (sexual arousal from someone whose age is older and that of a different generation), hebephilia (men that are sexually aroused by aroused by teenagers), kleptolagnia (sexual arousal from stealing), retifism (sexual arousal from shoes), scatophilia (sexual arousal via making telephone calls, using vulgar language, and/or trying to elicit a reaction from the other party), scoptophilia (sexual arousal by watching others [typically engaged in sexual behaviour] without their consent, and more usually referred to as voyeurism), and somnophilia (sexual arousal from fondling strangers in their sleep). The multiplicity of co-existent paraphilias (including anthropophagolagnia) is highlighted by the Wikipedia entry on Jeffrey Dahmer:
“Dahmer readily admitted to having engaged in a number of paraphilic behaviors, including necrophilia, exhibitionism, hebephilia, fetishism, pygmalionism, and erotophonophilia. He is also known to have several partialisms, including anthropophagy (also known as cannibalism). One particular focus of Dahmer’s partialism was the victim’s chest area. By his own admission, what caught his attention to Steven Hicks hitchhiking in 1978 was the fact the youth was bare-chested; he also conceded it was possible that his viewing the exposed chest of Steven Tuomi in 1987 while in a drunken stupor may have led him to unsuccessfully attempt to tear Tuomi’s heart from his chest. Moreover, almost all the murders Dahmer committed from 1990 onwards involved a ritual of posing the victims’ bodies in suggestive positions – many pictures taken prior to dismemberment depict the victims’ bodies with the chest thrust outwards. Dahmer also derived sexual pleasure from the viscera of his victims; he would often masturbate and ejaculate into the body cavity and at other times, literally used the internal organs as a masturbatory aid”.
Almost nothing is known empirically about anthropophagolagnia except that it is very rare and that almost all information about it comes from serial killers that have been caught. Explanations for the development of anthropophagolagnia can only be speculated but are likely to be no different from the development of other paraphilic behaviour. Hickey (citing Irwin Sarason and Barbara Sarason’s Abnormal Psychology textbook) notes five key explanations for the development of paraphilias (reproduced below verbatim):
- Psychodynamic – paraphilic behavior as a manifestation of unresolved conflicts during psychosexual development;
- Behavioral – paraphilia is developed through conditioning, modeling, reinforcement, punishment, and rewards, the same process that normal sexual activity is learned;
- Cognitive – paraphilia become substitutes for appropriate social and sexual functioning or the inability to develop satisfying marital relationships;
- Biological – heredity, prenatal hormone environment, and factors contributing to gender identity can facilitate paraphilic interests. Other explanations are linked to brain malfunctioning and chromosomal abnormalities;
- Interactional – that development of paraphilia is a process that results from psychodynamic, behavioral, cognitive, and biological factors.
As an eclectic, I favour the interactional explanation for the existence of anthropophagolagnia but also believe that the most important influences are the behavioural aspects via classical and operant conditioning processes.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.
Hall, J. (2013). ‘Black Jesus’ murder: Leader of 6,000-strong cannibal rape cult hacked to death by villagers in Papua New Guinea jungle after killing yet again. The Independent, August 30. Located at: http://www.independent.co.uk/news/world/asia/black-jesus-murder-leader-of-6000strong-cannibal-rape-cult-hacked-to-death-by-villagers-in-papua-new-guinea-jungle-after-killing-yet-again-8791967.html
Hickey, E. W. (Ed.). (2003). Encyclopedia of Murder and Violent Crime. London: Sage Publications
Hickey, E. W. (2010). Serial Murderers and Their Victims (Fifth Edition). Pacific Grove, CA: Brooks/Cole.
Purcell, C., and B. Arrigo. (2001). Explaining paraphilias and lust murder: Toward an integrated model. International Journal of Offender Therapy and Comparative Criminology, 45(1), 6–31.
Sarason, I. G. and B. R. Sarason. (2004). Abnormal Psychology, 11th Edition. Upper Saddle River, N.J.: Prentice Hall.
Wikipedia (2014). Jeffrey Dahmer. Located at: http://en.wikipedia.org/wiki/Jeffrey_Dahmer
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
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: http://en.wikipedia.org/wiki/Blood_as_food
Wikipedia (2013). Hematophagy. Located at: http://en.wikipedia.org/wiki/Hematophagy
At present, exercise addiction is not officially recognised in any medical or psychological diagnostic frameworks such as the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) or the World Health Association’s International Classification of Diseases. However, there has been a lot of research into whether exercise can be classed as a bona fide addiction. In spite of the widespread usage of the term ‘exercise addiction’ there are many different terminologies that describe excessive exercise syndrome. Such terms include ‘exercise dependence’, ‘obligatory exercising’, ‘exercise abuse’, and ‘compulsive exercise’. Exercise addiction has been conceptualised as a behavioural addiction. The symptoms and consequences of exercise addiction have often been characterised by six common components of addiction: salience, mood modification, tolerance, withdrawal symptoms, personal conflict, and relapse.
For some people, exercise addiction is a primary problem in the person’s life whereas in others it can be a secondary problem as a consequence of other psychological dysfunctions (like eating disorders such as anorexia nervosa). In the former case, the dysfunction is considered as primary exercise addiction, while in the latter case it is termed as secondary exercise addiction because it co-occurs with another dysfunction. The differentiating feature between the two is that in primary exercise addiction the objective is the exercise itself, whereas in secondary exercise addiction the objective is weight loss, where excessive exercise is one of the primary means in achieving the desired objective.
The incentive or motive for fulfilling planned exercise is an important distinguishing characteristic between addicted and nonaddicted exercisers. The reason people exercise is often for an intangible reward such as feeling in shape, looking good, being with friends, staying healthy, building muscles, losing weight, etc. The personal experience of the anticipated reward reinforces and strengthens the exercise behaviour. Committed exercisers maintain their exercise for benefiting or gaining from their activity and thus, their behaviour is motivated via positive reinforcement. However, empirical research has demonstrated that addicted exercisers have to exercise in order to avoid negative feelings or withdrawal. The individual’s exercise may become a chore that has to be fulfilled, or otherwise an unwanted event would occur (such as the inability to cope with stress, or gaining weight, becoming moody, etc.). Every time a person undertakes behaviour to avoid something negative, bad, and/or unpleasant, the motive behind that behaviour acts as a negative reinforcement. In these situations, the person feels they have to do it rather than wanting to do it.
Mood modification is a key factor among the symptoms of exercise addiction and suggests there is a self-medication aspect of exercise that facilitates the distinction between normal and abnormal exercise. Addicts do not simply exercise to experience the joy of it, but rather to escape negative, unpleasant feelings and everyday difficulties.
The Exercise Addiction Inventory is one of the most recent and most widely used screening tools in the research area of exercise addiction, primarily because of its brevity and excellent psychometric properties (i.e., reliability and validity). The EAI comprises only six statements, each corresponding to one of the symptoms in the ’components’ model of addiction. Each statement is rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The EAI cut-off score for individuals considered at-risk of exercise addiction is 24 out of 30. To date, the only nationally representative study examining exercise addiction is a study that I co-authored with some Hungarian colleagues. We surveyed over 2,700 Hungarian adults aged 18–64 years and assessed exercise addiction using the EAI. Results showed that the proportion of the people at risk for exercise addiction was 0.5%.
There are numerous theories that deal with both the causes of exercise addiction and the process and mechanisms of its development and maintenance. A significant number of psychological theories are based on learning theory or the cognitive psychology approach. According to the theory of functioning, both positive reinforcers (e.g., a feeling of euphoria following exercise or muscle growth from exercise) and negative reinforcers (e.g. an end to unpleasant feelings through exercise or avoidance of the presumed negative effect of missed exercise) may lie behind the development and maintenance of exercise addiction which, according to the fundamental principles of learning theory, may contribute to the establishment of compulsive and addictive exercise that may be viewed as maladaptive.
One of my research colleagues, Dr. Attila Szabo stresses the role of cognitive appraisal mechanisms in the development of the vicious cycle that leads to excessive exercise. The process starts when the habitual exerciser uses exercise as a means of coping with stress, and the affected individual learns to depend on exercise at times of stress. The addicted exerciser is then trapped in a vicious cycle of needing increased amounts of exercise to deal with the consistently increasing life stress, part of which is caused by exercise itself.
It also appears that the issue of self-assessment represents a further significant factor among the psychological factors in the sense that during exercise, the physical strength experienced through exercise in a person dissatisfied with his or her body or body image contributes to the formation of a more positive self-image and self-assessment. It has also been shown that exercise activities (such as weightlifting) have a positive effect on body image and self-esteem both in men and in women. Perfectionism, obsessive-compulsive functioning, and heightened anxiety have also been claimed to be determining factors in exercise addiction.
The public promotion of healthy and appropriate exercise patterns may reduce the incidence of exercise addiction. It is important in public health programs and campaigns to (i) stress the healthy nature of regular exercise and (ii) communicate the message that exercise when taken to excess can be potentially harmful. It is important to raise awareness of potential harm within the population of regular exercisers. Some psychologists claim that individuals with exercise addiction have a poor understanding of the negative health consequences of excessive exercising, of the mechanism of exercise adaptation, and the need for rest between exercise sessions. The use of education may be an effective step in the prevention and treatment of exercise addiction.
As with other addictive disorders, the environment of regular exercisers also plays a significant role in recognising this condition early. In more severe cases psychotherapeutic interventions may be needed. When treating exercise addiction, abstinence from exercise may not be a required and/or realistic goal, because exercise has many benefits for health and no one would advocate doing no exercise. Therefore, the typical treatment goal would more likely be be to return to moderate and controlled exercise. In some cases, a different form of exercise may be recommended.
Joanna is a 25-year old student, well-educated female, from a stable family background, who realized that she had a problem surrounding exercise, and more specifically the martial art Jiu-Jitsu. Here, Joanna’s behavior is described in terms of the main components of addiction:
- Salience: Jiu-Jitsu is the most important activity in Joanna’s life. Even when not actually engaged in the activity, she is thinking about the next training session or competition. She estimates that she spends approximately six hours a day (and sometimes much more) involved in training (e.g., weight training, jogging, general exercise, etc.).
- Tolerance: Joanna started Jiu-Jitsu at an evening class once a week during her teenage years and built up slowly over a period of about five years. She now exercises every single day, and the lengths of the sessions have become longer and longer (suggesting tolerance).
- Withdrawal: Joanna claims she becomes highly agitated and irritable if she is unable to exercise. She claims she also gets headaches and feels nauseous if she goes for more than a day without training or has to miss a scheduled session.
- Mood modification: Joanna experiences mood changes in a number of ways. She feels very high and ‘buzzed up’ if she has done well in a Jiu-Jitsu competition (especially so if she wins). She also feels high if she has trained hard and for a long time.
- Conflict: Joanna’s relationship with her long-term partner ended as a result of her exercise. She claimed she never spent much time with him and was not even bothered about their break-up. Her university work suffered because of the lack of time and concentration.
- Loss of control: Joanna claims she cannot stop herself engaging in exercise when she “gets the urge”. Once she has started, she has to do a minimum of a few hours of exercise.
- Relapse: Joanna has continually tried to stop and/or cut down but claims she cannot. She becomes highly anxious if she is unable to engage in exercise and then has to go out and train to make herself feel better. She is well aware that exercise has taken over her life but feels powerless to stop it.
- Negative consequences: Joanna spends money beyond her means to maintain her exercising habit (e.g., on entrance fees for weight training, swimming, entrance fees enter Jiu-Jitsu tournaments across the country, etc.). She has resorted to socially unacceptable means (e.g., stealing) in order to get money to fund herself
In short, exercise is the most important thing in Joana’s life, and the number of hours engaged in physical activity per week has increased substantially over a five-year period. She displays withdrawal symptoms when she does not exercise, and experiences euphoric experiences related to various aspects of her exercising (e.g., training hard, winning competitions, etc.). She experiences conflict over exercise in many areas of her life and acknowledges she has a problem. Furthermore, she has lost friends, her relationship has broken down, her academic work has suffered, and she has considerable debt.
Note: An expanded version of this article was first published by Rehabs.com
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
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In a previous blog I briefly examined clinical vampirism as a sexual paraphilia. In that blog I noted that there had been very little empirical research on clinical vampirism and that most of what is known comes from clinical case studies. Furthermore, vampirism (i) is rarely a single clinical condition, (ii) may or may not be associated with other psychiatric and/or psychological disorders (e.g., severe psychopathy, schizophrenia, hysteria, mental retardation), and (iii) may or may not necessarily include sexual arousal. Other related conditions include odaxelagnia (deriving sexual pleasure from biting), haematolagnia (deriving sexual satisfaction from the drinking of blood), and haematophilia (deriving sexual satisfaction from blood in general), and auto-haemofetishism (i.e., deriving sexual pleasure from sight of blood drawn into a syringe during intravenous drug practice).
More recently I was contacted by a female ‘vampire’ (I use the term lightly in this instance) who has read my original article wanted to share her story with me. She gave me permission to disseminate her story with my blog readers on the understanding that I guaranteed her anonymity, confidentiality, and used her preferred name of ‘Countess Maria’ (CM) throughout the article. (She also signed herself as ‘The Young Madam’ but I will use CM for the remainder of this article). Obviously, I have no way of verifying anything that CM communicated to me, but on a personal level I have no reason to doubt the veracity of her claims. All of our communication was via email under her real name (which I then checked out online on a specific social networking site and I am 100% sure that she is who she says she is). She also said she “would be honored to have you feature my story. I have answered your questions…as I honor your intellect and respect…being a professor is indeed a respectable, hardy, and challenging profession which is why I greatly respect an honor such profession”. More specifically, she added:
CM: “Whom I share this information must take it to the grave with them; except for you. You may share my story if and only if you use my name I have used for years ‘Countess Marie’. I do indeed consider myself a Countess due to what I have endured through humanitarian efforts as well as my ever strong want, need, and desire to help humanity – even if humanity shuns me for who I am”.
I asked CM for some socio-demographic information and she told me that she was 23 years of age, described herself as an African American and was currently employed as a Pharmacy Technician. Based on what she told me, she was well educated with various medical qualifications including Pharmacy Technician and Animal Care Certification. I also asked her about her religious beliefs and she responded: “Christian with great noble intent (‘I will gladly share my last piece of bread with my fellow man’). I live by that statement and I intend to follow through”. She also went ion to say: “I am finally in my studied job, as a Pharmacy Technician. I have always had a thing for helping people…this is just one if the many ways I can help. My dream in life is to be a great humanitarian and grow to greatness in helping those around me…I love who I am, and I am always wanting to follow my path.
In her account, CM didn’t really label herself a vampire but admitted that she liked drinking blood, and that many of the acts she engaged in would be labelled as vampire-like by others. She also talked about her first experiences of blood-sucking:
CM: “It is my understanding that you wish to hear about my further expansion on my clinical vampirism. Truthfully, I don’t really put a label on what it is I do. I have been consuming blood since I was young. The first cut I ever got was from a tree branch. I sucked my arm for several hours because the taste was delicious”.
At that point, CM didn’t really view her activity as in any way wrong but over time she began to realize that blood sucking was not considered normal behaviour and that she was socially ostracized by those who knew about her love of blood:
CM: “As I furthered in age through the years I noticed that I was considered different and odd, but I kept to myself about it. My love, my best friends, and you are the only people to know I consume blood…I would also like to add I have been called everything in the book for consuming blood; Monster, Demon, Grim’s Helper, and all the names in the middle…[Even] my friends called me [these things] at first because they did not understand what it mean for me”
However, CM went to great lengths to tell me that her love of blood did not involve the sucking of blood from other humans:
CM: “Make no mistake…I have never consumed blood from any human being – [only] myself. I consume pork blood, beef blood, and if that cannot be obtained I buy steaks and cook them very rare just enough for blood to spill out of it. I enjoy eating food, but it’s not really fun if it lacks in my nutrition. I add blood to juice, tea, desserts, cakes, salads, and disguise it in all sorts of ways”.
CM claimed she would never do anything that impacted on other humans and that morally it would be wrong to enforce her own beliefs and desires on others. She also believes that blood consumption is what keeps her alive:
“I never feed anyone else my blood food. I cook human food properly for guests for I know I am the only one who enjoys the taste of blood. To many, it is bitter and irony-metallic tasting. I cannot relate, due to the fact that for me, it tastes like fine wine. Without blood, I know that I would surely die. I need blood to live. I have always felt that way. Nothing on Earth will ever change my thoughts on the matter. I love blood…To me blood is life or death”.
CM also told me she had been diagnosed with anemia and I asked her whether believed that her love of blood may be because she has anemia:
“I will always love blood. I know that as far as my health goes, it actually favors blood consumption. I was told I almost died by slowly falling into a coma from sleeping for almost 4 straight days. The entire time I was asleep it only felt like seconds, but when I awoke, everyone was worried…I was diagnosed with being anemic, as well as hyperthyroidism. My hyperthyroidism is such [that] I will be on Levothyroxin until the day I die. My blood naturally lacks the iron (due to being anemic) so consuming blood helps me in many ways…I feel that my anemia further shows me that when I feel dizzy or “off centered” that I should consume blood. I only consume pig or beef blood…NEVER human blood”.
As she had read my article clinical vampirism as a sexual paraphilia I also asked CM if her consuming of blood was in any way sexually motivate. She responded by saying:
“The sight of blood is a turn on for me, but only inside of a container. If someone is bleeding of course I would help aid them and stop the pain. If I see frozen blood in the grocery store or walk in the meat section at the market for too long, all I can smell is the blood, which causes arousal for me. I don’t stay in butcher shops long for that reason”.
This suggests that blood for CM (in some circumstances) is sexually arousing and that there may be paraphilic elements in her reason for liking blood. Whether CM is typical of other ‘vampires’ is not clear. But given the little we know about people that love drinking blood, I am grateful to CM for her time in answering my questions and her honesty in relation to the development and motivations underpinning her hobby.
Benezech, M., Bourgeois, M., Boukhabza, D. & Yesavage, J. (1981). Cannibalism and vampirism in paranoid schizophrenia. Journal of Clinical Psychiatry, 42(7), 290.
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Jaffe, P., & DiCataldo, F. (1994). Clinical vampirism: Blending myth and reality. Bulletin of the American Academy of Psychiatry and the Law, 22, 533-544.
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Prins, H. (1985). Vampirism: A clinical condition. British Journal of Psychiatry, 146, 666-668.
Vanden Bergh, R. L., & Kelly, J. F. (1964). Vampirism: A review with new observations. Archives of General Psychiatry, 11, 543-547.
Wilson N. (2000) A psychoanalytic contribution to psychic vampirism: a case vignette. American Journal of Psychoanalysis, 60, 177-86.
Yates, P.M., Hucker, S.J. & Kingston, W.A. (2008). Sexual sadism: Psychopathology and theory. In Laws, D.R. & O’Donohue, W.T. (Eds.), Sexual Deviance: Theory, Assessment and Treatment. pp.213-230. New York: Guildford Press.
A couple of weeks ago I wrote a blog on why problem gambling should be considered a health issue. Earlier this week, I came across an interesting study carried out by jackpot.co.uk who surveyed 2,131 online gamblers (58% males and 42% female) about their health. After the self-reported data had been collected, the gamblers were classed into one of nine categories based on the casino game type that the gambler played most often (i.e., slot machines, video poker, blackjack, roulette, dice/craps, baccarat, poker, pai gow, and ‘other’). The data were then tabulated so that all the health variables (including obesity) corresponded to the gambler’s preferred casino game.
I was interested in the findings not only because I am a Professor of Gambling Studies, but also because I was a member of the Department of Health’s ‘Expert Working Group on Sedentary Behaviour, Screen Time and Obesity’ (a reference to our final report to the British government can be found in the ‘Further Reading’ section below). The study took an objective measurement of physical condition by asking each gambler their height (centimetres) and their weight (kilograms) to calculate each person’s Body Mass Index (BMI) by dividing the gamblers’ weight by height (metres) and dividing by height again (for example, someone who weighs 80kg and is 180cm tall, the BMI is 24.1 as this is 80/1.80)/1.80). The survey then asked s few general health and lifestyle questions (similar to ones that we have used in the last few British Gambling Prevalence Surveys:
- Do you normally drink more than the recommended limit for weekly alcohol consumption (21 units of alcohol for men and 14 for women)? (Yes/No)
- Do you smoke regularly? (Yes/No)
- Do you normally engage in at least 30 minutes of physical activity, 5 times per week? (Yes/No)
Overall, the survey found that British casino gamblers as a group were no less healthy than the rest of the British population, with an average Body Mass index (BMI) of 27 (which is the same as the UK national average). However, the survey also reported that the average BMIs, health, and lifestyle choices (such as smoking cigarettes, engaging in exercise, and drinking alcohol varied considerably depending on the casino games that the respondents played. Here are some of the main findings:
- Slots players were the least healthy. They took less exercise and had an average BMI of 31, pushing them into the category of obese (which is linked to increased chance of developing illnesses such as Type 2 diabetes and reduced life expectancy)
- Roulette, blackjack, video poker and craps/dice players were not far behind slots players, each having BMI levels higher than the national average.
- Those that played poker, baccarat and Pai Gow had an average BMI of 25 or under (well within the normal range recommended by the World Health Organisation.
- Whilst drinking levels might be reasonably high among poker players, they were very exercise conscious, with 58% engaging in physical activity for at least 30 minutes, five times a week. For slots players the figure was 27% meeting this government recommended target.
- Overall slots players drink the most, with 24.1% drinking over the recommended weekly limit. Poker players are not far behind on 23%. Female slots players were the biggest drinking subgroup, closely followed by male poker players.
- Slots players also smoked more, with 24% being regular smokers (compared to the UK national average of 20%). Blackjack and roulette players smoked slightly more than average, on 21% and 22% respectively, while poker players smoked slightly less than average, on 19.5%.
None of these results is overly surprising as there are many studies (including my own) showing comorbidity between gambling and other potentially addictive behaviours. However, very few academic studies have ever looked at these health variables by game type. Although this was not an academic study, the results will likely be of interest to those in the gambling studies field.
The survey also examined the most common platform on which the gamblers played casino games. The most common was the desktop computer (65%), followed by mobiles and tablets (20%) and land-based casinos (14%). This is not surprising given the survey was completed by online gamblers. Interestingly, desktop use was linked to higher levels of obesity, drinking and smoking. This is something that I would expect given that online gambling is the most sedentary of these activities.
There are (of course) some limitations with the data collected particularly as it comprised a self-selected sample of online gamblers that played via jackpot.co.uk websites. We have no idea as to whether the sample is representative of all online gamblers but as I noted above, it is no surprise that online gamblers preferred playing casino games online compared to offline (i.e., land-based casinos). The data were also self-report and are therefore open to any number of individual biases including recall biases and social desirability biases. Also, we have no geographical breakdown of the sample as the internet (by definition) is global. However, the sample size is good in comparison to many published studies on gambling and the sample included individuals that were actually gamblers (as opposed to university undergraduates or members of the general public). According to Sam Marsden (editor of jackpot.co.uk and author of the report):
“There’s an undeniable link connecting passive games like slots and video poker to unhealthy, sedentary lifestyles. On the other hand, games that require concentration, strategy and some physical stamina like poker and blackjack seem to fare much better in the health stakes. It seems it’s less a case of ‘you are what you eat’ and more ‘you are what you play’.”
Although such a conclusion could be argued to be PR spin on the findings, the results suggest that more rigorous studies could be carried out in the area including secondary analyses of the robust datasets that already exist including the British Gambling Prevalence Surveys, the English Health Surveys, and the Scottish health Surveys.
Biddle, S., Cavill, N., Ekelund, U., Gorely, T., Griffiths, M.D., Jago, R., et al. (2010). Sedentary Behaviour and Obesity: Review of the Current Scientific Evidence. London: Department of Health/Department For Children, Schools and Families (126pp).
Griffiths, M.D. (2001). Gambling – An emerging area of concern for health psychologists. Journal of Health Psychology, 6, 477-479.
Griffiths, M.D. (2004). Betting your life on it: Problem gambling has clear health related consequences. British Medical Journal, 329, 1055-1056.
Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association (ISBN 1-905545-11-8).
Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2010). Gambling, alcohol consumption, cigarette smoking and health: findings from the 2007 British Gambling Prevalence Survey. Addiction Research and Theory, 18, 208-223.
Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2011). Internet gambling, health. Smoking and alcohol use: Findings from the 2007 British Gambling Prevalence Survey. International Journal of Mental Health and Addiction, 9, 1-11.
Marsden, S. (2014). Booze, bets, and BMI. Jackpot.co.uk, October 6. Located at: http://www.jackpot.co.uk/online-casino-articles/booze-bets-bmi
Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.
Wardle, H., Griffiths, M.D., Orford, J., Moody, A. & Volberg, R. (2012). Gambling in Britain: A time of change? Health implications from the British Gambling Prevalence Survey 2010. International Journal of Mental Health and Addiction, 10, 273-277.
Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.
Wardle, H., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.
Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M. D., Constantine, R., & Pigott, S. (2007). The British Gambling Prevalence Survey 2007. London: National Centre for Social Research.
In previous blogs I have looked at pica (i.e., the eating of non-nutritive items or substances) and subtypes of pica such as geophagia (eating of soil, mud, clay, etc.), pagophagia (eating of ice), acuphagia (eating of metal), and coprophagia (eating of faeces). It wasn’t until I started to research on specific sub-types of pica, that I discovered how many different types of non-food substances had been identified in the academic and clinical literature. For instance, Dr. V.J. Louw and colleagues provided a long list in a 2007 issue of the South African Medical Journal including cravings for the heads of burnt matches (cautopyreiophagia), cigarettes and cigarette ashes, paper, starch (amylophagia), crayons, cardboard, stones (lithophagia), mothballs, hair (trichophagia), egg shells, foam rubber, aspirin, coins, vinyl gloves, popcorn (arabositophagia), and baking powder. Most of these are generally thought to be harmless but as Louw and colleagues note, a wide range of medical problems have been documented:
“These include abdominal problems (sometimes necessitating surgery), hypokalaemia, hyperkalaemia, dental injury, napthalene poisoning (in pica for toilet air-freshener blocks), phosphorus poisoning (in pica for burnt matches), peritoneal mesothelioma (geophagia of asbestos-rich soil), mercury poisoning (in paper pica), lead poisoning (in dried paint pica and geophagia), and a pre-eclampsia-like syndrome (baking powder pica)”.
In the clinical literature, the eating of paper has been occasionally documented (although anecdotal evidence suggests this is fairly common and I remember doing it myself as a child). A recent review paper on pica by Dr. Silvestre Frenk and colleagues in the Mexican journal Boletín Médico del Hospital Infantil de México highlighted dozens of pica-subtypes and created many new names for various pica sub-types. They proposed that people who eat paper display ‘papirophagia’ (in fact if you type ‘papirphagia’ into Google, you only get one hit – the paper by Silvestre and colleagues – although this blog may make it two!). Eating paper is not thought to be particularly harmful although I did find a case of mercury poisoning because of ‘paper pica’ (as the authors – Dr. F. Olynk and Dr. D. Sharpe – called it) in a 1982 issue of the New England Journal of Medicine.
One sub-type of papirophagia is the eating of toilet paper. As far as I am aware, there is only one case study in the literature and this was published back in 1981, Dr. J. Chisholm Jr. and Dr. H. Martín in the Journal of the National Medical Association. They described the case of a 37-year old black woman with an “unusually bizarre craving” for toilet tissue paper. The authors reported that:
“[The] woman was referred for evaluation of disturbed smell and loss of taste for over one year. These were associated with chronic fatigue and listlessness. During this same period of time, she rather embarrassedly admitted to an overwhelming desire to eat toilet tissue. Frequently, she would awaken at night and dash to her bathroom to eat toilet tissue. No other type(s) of pica were admitted. In addition, she gave a long history of menorrhagia and frequently passed vaginal blood clots during her menses. Her libido was normal and there was no history of poor wound healing, skin or mucous membrane lesions, or intestinal symptoms. Her dietary history suggested a high carbohydrate diet, and due to a mild exogenous obesity she intermittently resorted to a vegan-like diet that included beans and various seeds”
A variety of medical tests were carried out and she was diagnosed with combined iron and zinc deficiency. She was treated with iron and zinc tablets and within a week, both her taste and smell had returned, and her energy levels greatly improved. Zinc deficiencies can lead to a wide variety of clinical disorders including loss of small and taste, anorexia, dwarfism (i.e., growth retardation), impaired wound healing, and geophagia. The woman’s (sometimes) vegan diet may have been to blame for her zinc deficiency as the authors noted that:
“Although vegetables contain zinc, vegans should be made aware that zinc from plant sources is not readily absorbed because naturally occurring phytates, particularly high in beans and seeds, reduce zinc gastrointestinal absorption. Carbohydrates are very poor sources of zinc. Chronic iron deficiency secondary to chronic menorrhagia accounts well for the anemia, fatigue, and unusual pica for toilet tissue noted in this patient”.
Paper pica has occasionally been mentioned in other academic papers although details have typically been limited. For instance, a 1995 paper in the journal Birth by Dr. N.R. Cooksey on three cases of pica in pregnancy reported that one of the women chewed non-perfumed blue toilet paper during the first trimester of her pregnancy (and was forced by her mother to stop). There was also a 2003 paper published by Dr. Dumaguing in the Journal of Geriatric Psychiatry and Neurology examining pica in mentally ill geriatrics. One of the cases mentioned was a 76-year old patient that not only ingested their medication (an emollient cream for arthritis) but was also recorded eating toilet paper, napkins, Styrofoam cups, crayons, and other patients’ medications.
A more recent 2008 paper by Dr. Sera Young and her colleagues in the journal PLoS ONE, critically reviewed procedures and guidelines for interviews and sample collection in relation to pica substances. In describing the protocols involved, they referred to paper pica in the questions that should be asked:
“What is the local name, brand name, or type of pica substance desired or consumed? This will help others to know if this substance has already been studied and assist interested researchers in obtaining subsequent samples at a later date. Furthermore, different manufactured products may contain different materials, e.g. Crayola chalkboard chalk contains slightly different ingredients from other brands. Similarly, the consequences of toilet tissue paper consumption are different from those of eating pages of a novel; information would be lost if the substance was simply described as paper. For these reasons, the substance consumed should be described in as much detail and as accurately as possible”.
Personally (and based on anecdotal evidence), I think that papirophagia is not overly rare (especially among children – although I admit this may be more out of curiosity that craving) but the clinical literature suggests that it is a fairly rare disorder found amongst distinct sub-groups (pregnant women, the mentally ill). Given the fact that for most people eating paper would not cause any problems, this would provide the main reason why so few cases end up seeking medical, clinical, and/or psychological help.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Chisholm Jr, J. C., & Martín, H. I. (1981). Hypozincemia, ageusia, dysosmia, and toilet tissue pica. Journal of the National Medical Association, 73(2), 163-164.
Cooksey, N.R. (1995). Pica and olfactory craving of pregnancy: How deep are the secrets? Birth, 22, 129-137.
Dumaguing, N.I., Singh, I., Sethi, M., & Devanand, D.P. (2003). Pica in the geriatric mentally ill: unrelenting and potentially fatal. Journal of Geriatric Psychiatry and Neurology, 16, 189-191.
Frenk, S., Faure, M.A., Nieto, S. & Olivares, Z. (2013). Pica. Boletín Médico del Hospital Infantil de México, 70(1), 55-61
Louw, V.J., Du Preez, P., Malan, A., Van Deventer, L., Van Wyk, D., & Joubert, G. (2007). Pica and food craving in adults with iron deficiency in Bloemfontein, South Africa. South African Medical Journal, 97, 1069-1071.
Olynyk, F., & Sharpe, D. H. (1982). Mercury poisoning in paper pica. The New England Journal of Medicine, 306, 1056 -1057.
Young, S.L., Wilson, M.J., Miller, D., Hillier, S. (2008). Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS ONE, 3(9), e3147. doi:10.1371/journal.pone.0003147
Muscle Dysmorphia (MD) describes a condition characterised by a misconstrued body image in individuals interpret their body size as both small and weak even though they may look normal or even be highly muscular. Those experiencing the condition typically strive for maximum fat loss and maximum muscular build. MD can have potentially negative effects on thought processes including depressive states, suicidal thoughts, and in extreme cases, suicide attempts. These negative psychological states have also been linked with concurrent use of Appearance and Performance Enhancing Drugs (APED) including Anabolic Androgenic Steroids (AAS).
MD was originally categorised in 1993 by Dr. H.G. Pope and colleagues (in the journal Comprehensive Psychiatry) as Reverse Anorexia Nervosa, due to characteristic symptoms in relation to body size. It has been considered to be part of the spectrum of Body Dysmorphic Disorders (BDD) referring to a range of conditions that tap into issues surrounding body image and eating behaviours. Consequently, there is a lack of consensus amongst researchers whether MD is a form of BDD, Obsessive-Compulsive Disorder (OCD) or a type of eating disorder. Earlier this year, Andy Foster, Dr. Gillian Shorter and I published a paper in the Journal of Behavioral Addictions about the ‘Addiction to Body Image’ model, and arguing that MD could perhaps be conceptualized as an addiction.
Our ‘Addiction to Body Image’ (ABI) model attempts to provide an operational definition and to introduce a standard assessment across the research area. The ABI model uses my addiction components model (outlined is a previous blog) as the framework in which to define muscle dysmorphia as an addiction. For the purposes of our paper, body image was defined using Sarah Grogan’s definition (from her 2008 book Body image: Understanding body dissatisfaction in men, women, and children) who said it was a person’s “perceptions, thoughts and feelings about his or her body”. We argued that the addictive activity in MD is the maintaining of body image via a number of different activities such as bodybuilding, exercise, eating certain foods, taking specific drugs (e.g., anabolic steroids), shopping for certain foods, food supplements, and/or physical exercise accessories, etc.).
In the ABI model, the perception of the positive effects on the self-body image is accounted for as a critical aspect of the MD condition. The maintenance behaviours of those with ABI may include healthy changes to diet or increases in exercise. However, such behaviours can hide or mislead those with ABI away from the negative thought processes that are driving their addiction. It is in the cognitive dysfunction of MD where we believe there is a pathological issue, and why the field has encountered problems with the criteria for the condition. The attempt to explain MD in the same manner as other BDDs may not be adequate due to the cognitive dysfunction occurring in the context of the potentially positive physical effects via improvements in shape, tone, and/or health of the body.
We also argued that there is a difference in the cognitive dysfunction with a misconstrued self-body image compared to other BDDs. The cognitive dysfunction causes the individual with MD to have a misconstrued view of their own body image, and the person believes they are small and puny. This negative mindset has the potential to cause depression and other disorders, and may facilitate the addiction. Unlike other conceptualizations of MD in the BDD literature, we would argue that the agent of the addiction is the perceived body image that is maintained by engaging in secondary behaviours such as specific types of physical activity and food. The most important thing in the life of someone with MD is how their body looks (i.e., their body image). The behaviours that the person with MD engages in (such as excessive exercise or disordered eating) are merely the vehicles by which their addiction (i.e., their perceived body image) is maintained.
Based on empirical evidence to date, we proposed that Muscle Dysmorphia could be re-classed as an addiction due to the individual continuing to engage in maintenance behaviours that cause long-term psychological damage. More research is needed to explore the possibilities of MD as an addiction, and how this particular addiction is linked to substance use and/or other comorbid health conditions. Controversy about the conceptual measurement of the condition, has led to a number of different scales adapted from different criteria that may not fully measure the experience of MD.
However, a group of questions that might test the applicability of the ABI approach to measuring and conceptualising MD have not been asked. Questionnaires such as the Exercise Addiction Inventory and the Bergen Work Addiction Scale (two scales that I co-developed) could be adapted to fit MD characteristics. Adequate conceptualisation is key to explore the clinically relevant condition. This new ABI approach may also have implications for diagnostic systems around similar conditions such as other BDDs or eating disorders.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Additional input: Andy Foster and Dr. Gillian Shorter
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