Category Archives: Eating disorders

Running up debt: A brief overview of our recent papers on exercise and shopping addictions

Following my recent blogs where I outlined some of the papers that my colleagues and I have published on mindfulness, Internet addiction, gaming addiction, youth gambling and other addictive behaviours, here is a round-up of recent papers that my colleagues and I have published on exercise addiction and shopping addictions (i.e., compulsive buying).

Griffiths, M.D., Urbán, R., Demetrovics, Z., Lichtenstein, M.B., de la Vega, R., Kun, B., Ruiz-Barquín, R., Youngman, J. & Szabo, A. (2015). A cross-cultural re-evaluation of the Exercise Addiction Inventory (EAI) in five countries. Sports Medicine Open, 1:5.

  • Research into the detrimental effects of excessive exercise has been conceptualized in a number of similar ways, including ‘exercise addiction’, ‘exercise dependence’, ‘obligatory exercising’, ‘exercise abuse’, and ‘compulsive exercise’. Among the most currently used (and psychometrically valid and reliable) instruments is the Exercise Addiction Inventory (EAI). The present study aimed to further explore the psychometric properties of the EAI by combining the datasets of a number of surveys carried out in five different countries (Denmark, Hungary, Spain, UK, and US) that have used the EAI with a total sample size of 6,031 participants. A series of multigroup confirmatory factor analyses (CFAs) were carried out examining configural invariance, metric invariance, and scalar invariance. The CFAs using the combined dataset supported the configural invariance and metric invariance but not scalar invariance. Therefore, EAI factor scores from five countries are not comparable because the use or interpretation of the scale was different in the five nations. However, the covariates of exercise addiction can be studied from a cross-cultural perspective because of the metric invariance of the scale. Gender differences among exercisers in the interpretation of the scale also emerged. The implications of the results are discussed, and it is concluded that the study’s findings will facilitate a more robust and reliable use of the EAI in future research.

Mónok, K., Berczik, K., Urbán, R., Szabó, A., Griffiths, M.D., Farkas, J., Magi, A., Eisinger, A., Kurimay, T., Kökönyei, G., Kun, B., Paksi, B. & Demetrovics, Z. (2012). Psychometric properties and concurrent validity of two exercise addiction measures: A population wide study in Hungary. Psychology of Sport and Exercise, 13, 739-746.

  • Objectives: The existence of exercise addiction has been examined in numerous studies. However, none of the measures developed for exercise addiction assessment have been validated on representative samples. Furthermore, estimates of exercise addiction prevalence in the general population are not available. The objective of the present study was to validate the Exercise Addiction Inventory (EAI; Terry, Szabo, & Griffiths, 2004), and the Exercise Dependence Scale (EDS; Hausenblas & Downs, 2002b), and to estimate the prevalence of exercise addiction in general population. Design: Exercise addiction was assessed within the framework of the National Survey on Addiction Problems in Hungary (NSAPH), a national representative study for the population aged 18–64 years (N = 2710). Method: 474 people in the sample (57% males; mean age 33.2 years) who reported to exercise at least once a week were asked to complete the two questionnaires (EAI, EDS). Results: Confirmatory Factor Analysis (CFA) indicated good fit both in the case of EAI (CFI = 0.971; TLI = 0.952; RMSEA = 0.052) and EDS (CFI = 0.938; TLI = 0.922; RMSEA = 0.049); and confirmed the factor structure of the two scales. The correlation between the two measures was high (r = 0.79). Results showed that 6.2% (EDS) and 10.1% (EAI) of the population were characterized as nondependent-symptomatic exercisers, while the proportion of the at-risk exercisers were 0.3% and 0.5%, respectively. Conclusions: Both EAI and EDS proved to be a reliable assessment tool for exercise addiction, a phenomenon that is present in the 0.3–0.5% of the adult general population.

Szabo, A., Griffiths, M.D., de La Vega Marcos, R., Mervo, B. & Demetrovics, Z. (2015). Methodological and conceptual limitations in exercise addiction research. Yale Journal of Biology and Medicine, 86, 303-308.

  • The aim of this brief analytical review is to highlight and disentangle research dilemmas in the field of exercise addiction. Research examining exercise addiction is primarily based on self-reports, obtained by questionnaires (incorporating psychometrically validated instruments), and interviews, which provide a range of risk scores rather than diagnosis. Survey methodology indicates that the prevalence of risk for exercise addiction is approximately 3 percent among the exercising population. Several studies have reported a substantially greater prevalence of risk for exercise addiction in elite athletes compared to those who exercise for leisure. However, elite athletes may assign a different interpretation to the assessment tools than leisure exercisers. The present paper examines the: 1) discrepancies in the classification of exercise addiction; 2) inconsistent reporting of exercise addiction prevalence; and 3) varied interpretation of exercise addiction diagnostic tools. It is concluded that there is the need for consistent terminology, to follow-up results derived from exercise addiction instruments with interviews, and to follow a theory-driven rationale in this area of research.

Andreassen, C.S., Griffiths, M.D., Pallesen, S., Bilder, R.M., Torsheim, T. Aboujaoude, E.N. (2015). The Bergen Shopping Addiction Scale: Reliability and validity of a brief screening test. Frontiers in Psychology, 6:1374. doi: 10.3389/fpsyg.2015.01374.

  • Although excessive and compulsive shopping has been increasingly placed within the behavioral addiction paradigm in recent years, items in existing screens arguably do not assess the core criteria and components of addiction. To date, assessment screens for shopping disorders have primarily been rooted within the impulse-control or obsessive-compulsive disorder paradigms. Furthermore, existing screens use the terms ‘shopping,’ ‘buying,’ and ‘spending’ interchangeably, and do not necessarily reflect contemporary shopping habits. Consequently, a new screening tool for assessing shopping addiction was developed. Initially, 28 items, four for each of seven addiction criteria (salience, mood modification, conflict, tolerance, withdrawal, relapse, and problems), were constructed. These items and validated scales (i.e., Compulsive Buying Measurement Scale, Mini-International Personality Item Pool, Hospital Anxiety and Depression Scale, Rosenberg Self-Esteem Scale) were then administered to 23,537 participants (Mage = 35.8 years, SDage = 13.3). The highest loading item from each set of four pooled items reflecting the seven addiction criteria were retained in the final scale, The Bergen Shopping Addiction Scale (BSAS). The factor structure of the BSAS was good (RMSEA=0.064, CFI=0.983, TLI=0.973) and coefficient alpha was 0.87. The scores on the BSAS converged with scores on the Compulsive Buying Measurement Scale (CBMS; 0.80), and were positively correlated with extroversion and neuroticism, and negatively with conscientiousness, agreeableness, and intellect/imagination. The scores of the BSAS were positively associated with anxiety, depression, and low self-esteem and inversely related to age. Females scored higher than males on the BSAS. The BSAS is the first scale to fully embed shopping addiction within an addiction paradigm. A recommended cutoff score for the new scale and future research directions are discussed.

Davenport, K., Houston, J. & Griffiths, M.D. (2012). Excessive eating and compulsive buying behaviours in women: An empirical pilot study examining reward sensitivity, anxiety, impulsivity, self-esteem and social desirability. International Journal of Mental Health and Addiction, 10, 474-489.

  • ‘Mall disorders’ such as excessive eating and compulsive buying appear to be increasing, particularly among women. A battery of questionnaires was used in an attempt to determine this association between specific personality traits (i.e., reward sensitivity, impulsivity, cognitive and somatic anxiety, self-esteem, and social desirability) and excessive eating and compulsive buying in 134 women. Reward sensitivity and cognitive anxiety were positively related to excessive eating and compulsive buying, as was impulsivity to compulsive buying. Somatic anxiety and social desirability were negatively related to compulsive buying. These preliminary findings indicate that excessive behaviours are not necessarily interrelated. The behaviours examined in this study appear to act as an outlet for anxiety via the behaviours’ reinforcing properties (e.g., pleasure, attention, praise, etc.). As a consequence, this may boost self-esteem. The findings also appear to indicate a number of risk factors that could be used as ‘warning signs’ that the behaviour may develop into an addiction.

Maraz, A., Eisinger, A., Hende, Urbán, R., Paksi, B., Kun, B., Kökönyei, G., Griffiths, M.D. & Demetrovics, Z. (2015). Measuring compulsive buying behaviour: Psychometric validity of three different scales and prevalence in the general population and in shopping centres. Psychiatry Research, 225, 326–334.

  • Due to the problems of measurement and the lack of nationally representative data, the extent of compulsive buying behaviour (CBB) is relatively unknown. The validity of three different instruments was tested: Edwards Compulsive Buying Scale, Questionnaire About Buying Behavior and Richmond Compulsive Buying Scale using two independent samples. One was nationally representative of the Hungarian population (N=2710) while the other comprised shopping mall customers (N=1447). As a result, a new, four-factor solution for the ECBS was developed (Edwards Compulsive Buying Scale Revised (ECBS-R)), and confirmed the other two measures. Additionally, cut-off scores were defined for all measures. Results showed that the prevalence of CBB is 1.85% (with QABB) in the general population but significantly higher in shopping mall customers (8.7% with ECBS-R, 13.3% with QABB and 2.5% with RCBS-R). Conclusively, due to the diversity of content, each measure identifies a somewhat different CBB group.

Maraz, A., Griffiths, M.D., & Demetrovics, Z. (2016). The prevalence of compulsive buying in non-clinical populations: A systematic review and meta-analysis. Addiction, 111, 408-419.

  • Aims: To estimate the pooled prevalence of compulsive buying behaviour (CBB) in different populations and to determine the effect of age, gender, location and screening instrument on the reported heterogeneity in estimates of CBB and whether publication bias could be identified. Methods: Three databases were searched (Medline, PsychInfo, Web of Science) using the terms ‘compulsive buying’, ‘pathological buying’ and ‘compulsive shopping’ to estimate the pooled prevalence of CBB in different populations. Forty studies reporting 49 prevalence estimates from 16 countries were located (n = 32 000). To conduct the meta-analysis, data from non-clinical studies regarding mean age and gender proportion, geographical study location and screening instrument used to assess CBB were extracted by multiple independent observers and evaluated using a random-effects model. Four a priori subgroups were analysed using pooled estimation (Cohen’s Q) and covariate testing (moderator and meta-regression analysis). Results: The CBB pooled prevalence of adult representative studies was 4.9% (3.4–6.9%, eight estimates, 10 102 participants), although estimates were higher among university students: 8.3% (5.9–11.5%, 19 estimates, 14 947 participants) in adult non-representative samples: 12.3% (7.6–19.1%, 11 estimates, 3929 participants) and in shopping-specific samples: 16.2% (8.8–27.8%, 11 estimates, 4686 participants). Being young and female were associated with increased tendency, but not location (United States versus non-United States). Meta-regression revealed large heterogeneity within subgroups, due mainly to diverse measures and time-frames (current versus life-time) used to assess CBB. Conclusions: A pooled estimate of compulsive buying behaviour in the populations studied is approximately 5%, but there is large variation between samples accounted for largely by use of different time-frames and measures.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Allegre, B., Souville, M., Therme, P. & Griffiths, M.D. (2006). Definitions and measures of exercise dependence, Addiction Research and Theory, 14, 631-646.

Allegre, B., Therme, P. & Griffiths, M.D. (2007). Individual factors and the context of physical activity in exercise dependence: A prospective study of ‘ultra-marathoners’. International Journal of Mental Health and Addiction, 5, 233-243.

Berczik, K., Szabó, A., Griffiths, M.D., Kurimay, T., Kun, B. & Demetrovics, Z. (2012). Exercise addiction: symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, 47, 403-417.

Berczik, K., Griffiths, M.D., Szabó, A., Kurimay, T., Kökönyei, G., Urbán, R. and Demetrovics, Z. (2014). Exercise addiction – the emergence of a new disorder. Australasian Epidemiologist, 21(2), 36-40.

Berczik, K., Griffiths, M.D., Szabó, A., Kurimay, T., Urban, R. & Demetrovics, Z. (2014). Exercise addiction. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.317-342). New York: Elsevier.

Griffiths, M.D. (1997). Exercise addiction: A case study. Addiction Research, 5, 161-168.

Griffiths, M.D., Szabo, A. & Terry, A. (2005). The Exercise Addiction Inventory: A quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39, 30-31.

Kurimay, T., Griffiths, M.D., Berczik, K., & Demetrovics, Z. (2013). Exercise addiction: The dark side of sports and exercise. In Baron, D., Reardon, C. & Baron, S.H., Contemporary Issues in Sports Psychiatry: A Global Perspective (pp.33-43). Chichester: Wiley.

Szabo, A. & Griffiths, M.D. (2007). Exercise addiction in British sport science students. International Journal of Mental Health and Addiction, 5, 25-28.

Terry, A., Szabo, A. & Griffiths, M.D. (2004). The Exercise Addiction Inventory: A new brief screening tool, Addiction Research and Theory, 12, 489-499.

Warner, R. & Griffiths, M.D. (2006). A qualitative thematic analysis of exercise addiction: An exploratory study. International Journal of Mental Health and Addiction, 4, 13-26.

Fat’s life: Another look inside the world of feederism

Online letter from Jill to ‘Dr. Feeder’: “I am a feedee from Boston in desperate need of a feeder. I have tried dieting and I know my mission is to be fat. I feel I can’t do it alone. I fantasize about meeting a dominant man who is a Feeder…How do I get fat on my own? What foods? Can you give me a sample daily diet?”

Response to Jill’s letter from ‘Dr. Feeder’: “See my article ‘How To Get Fat‘. The kinds of foods don’t matter so much. Eat what you enjoy the most, especially if it’s fattening. The more you enjoy overeating, the more you will overeat. A lot of variety is also important”.

In a previous blog on fat fetishism, I noted that the fetish also included ‘feederism’ and ‘gaining’ in which sexual arousal and gratification is stimulated through the person (referred to as the ‘feedee’) gaining body fat. Feederism is a practice carried out by many fat admirers within the context of their sexual relationships and is where the individuals concerned obtain sexual gratification from the encouraging and gaining of body fat through excessive food eating. Sexual gratification may also be facilitated and/or enhanced the eating behaviour itself, and/or from the feedee becoming fatter – known as ‘gaining’ – where either one or both individuals in the sexual relationship participate in activities that result in the gaining of excess body fat.

Since writing my previous article on the topic, I have briefly written about feederism in two of my academic papers on sexual paraphilias (one in the Archives of Sexual Behavior in relation to a case study I wrote on fart fetishism, and the other in the Journal of Behavioral Addictions on how the internet has facilitated scientific research into paraphilias – see ‘Further reading’ below). However, I was also interviewed for the Discovery Channel’s television programme Forbidden about American Gabi Jones from Colorado (aka ‘Gaining Gabi’) who appeared in the episode ‘Pleasure and Pain’.

At the time when the television programme was being recorded, Gabi weighed 490 pounds and her sole aim was to get even fatter and heavier (before she became a feedee she was 250 pounds). It is also her career and her thousands of online fans pay money who pay $20 a month to watch her eat as well as sending her food to eat (you can check out her online website here, but pleased be warned that it contains explicit sexual content). She also claims that she becomes sexually aroused when eating excessively.

When I indulge, I never rush. I take my time and treat all meals as very sexual experiences. I love being fat and the idea of getting large excites me…For as long as I remember, I always loved the idea of getting softer and being this piece of art that I am creating…My body is a work of art”.

She claims she does it to show that women can be empowered and that fat can be sexy. She’s also a campaigner for ‘fat acceptance’. However, the (US) National Association for the Advancement of Fat Acceptance (NAAFA) is anti-feederism. The NAAFA exists “to help build a society in which people of every size are accepted with dignity and equality in all aspects of life” but has specifically noted in its manifesto that:

“NAAFA supports an individual’s right to control all choices concerning his or her own body. NAAFA opposes the practice of feeders, in which one partner in a sexual relationship expects and encourages another partner to gain weight…That all bodies, of all sizes, are joyous and that individuals of all sizes can and should expect and demand respect from sexual partners for their bodies just as they are. That people of all sizes become empowered to demand respect for their bodies in the context of sexual relationships, without attempting to lose or gain weight in order to win a partner’s approval or attract or retain that partner’s desire”.

At the time she was interviewed, Gabi had two ‘feeders’ – one male (Kenyon, from Kansas, US) and one female (nicknamed ‘Hearts’, from Colorado). As the show’s production notes reported:

“Kenyon lives in a small town in Kansas…Gabi says that Kenyon has actually been a fan of hers since he was 12 or 13 [years old], he discovered her online. Gabi says that she wouldn’t have anything to do with him because he was not of age, but after [Kenyon’s 18th birthday she] accepted him into her life as her food slave. Kenyon says that he had fantasized for years about feeding her live in person…He is now totally devoted to Gabi and she is happy to have him as part of her ‘chosen family’ and hopes to move him out from Kansas to Colorado to live with her fulltime someday soon…Hearts makes sure that Gabi has all the food she could want and need. Gabi also feeds her. It’s not a sexual thing or anything – ‘we’re not lesbians, we’re just really close friends’ – but when they feed each other it’s ‘sexy and fun’. They met in college at the start of this year and haven’t left each other’s side since…Hearts is also gaining. Gabi got her into it one day when they were lying on her bed and Hearts noticed how soft Gabi’s tummy was. This made her decide she wanted to get fat too. Hearts is currently 201 pounds and her goal weight is 400 pounds…Gabi says there are two types of gainers – ‘feedees’ who’ll eat anything and ‘foodees’ who’ll eat only quality food, not junk. Gabi says she identifies more with a foodie”.

Academically, there have been an increasing number of papers published over the last few years. For instance, Dr. Lesley Terry and her colleagues have also published papers on feederism in the Archives of Sexual Behavior. The first was a case study (which I outlined in my previous blog), and more recently an interesting experiment that assessed individuals’ arousal to feederism compared to ‘normal’ sexual activity and neutral activity. A total of 30 volunteers (15 men and 15 women) were assessed using penile plethysmography (for the males) and vaginal photoplethysmography (for the females) – none of who were feeders or feedees. The paper reported that:

The volunteers were all shown sexual, neutral, and feeding still images while listening to audio recordings of sexual, neutral, and feeding stories. Participants did not genitally respond to feeding stimuli. However, both men and women subjectively rated feeding stimuli as more sexually arousing than neutral stimuli…the results of this study provide limited, but suggestive, evidence that feederism may be an exaggeration of a more normative pattern of subjective sexual arousal in response to feeding stimuli that exists in the general population.

Dr. Ariane Prohaska has published papers on feederism in such journals as the International Journal of Social Science Studies and Deviant Behavior. In one of her studies, she carried out a content analysis of feederism-related websites and examining feederism within heterosexual relationships. She concluded that feederism websites can take many forms such as groups, advice sites, personal ads, and pornography. The content analysis also revealed that the internet is a place where fat women can find a community of similar others to support them”. She also noted that although feedersim has been classified as a transgressive sexual behaviour, it “usually mimics patriarchal sex in the process”. She also claimed that at its extreme “feederism is an abusive behavior dangerous to the partner (usually the woman) who desires to gain weight as quickly as possible”. As highlighted in the case of Gabi above, Dr. Prohaska concludes that feederism is a communal behavior, but she also notes:

[W]hen it comes to feederism, men are still in control of the behavior and of how women are portrayed and treated as feedees. Although some of the websites discussed here may be advancing transgressive ideas about fat women as sexual beings, the objectification of women as sex objects is further perpetuated by these same websites. Bodies matter; normative ideas about fat women and heterosexual sex offline are perpetuated online. The internet is patriarchal as offline society. At its extreme, ideas about control over women involve manipulating their bodies using dangerous means, and the lines between consent and sexual assault are blurred. Consent is a difficult term to define in a culture where patriarchal values about sex have been internalized by members of society. Still, the internet has the potential to create loving, supportive communities for people of size rather than exploitative communities that mimic the offline world”.

Dr Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Charles, K., & Palkowski, M. (2015). Feederism: Eating, Weight Gain, and Sexual Pleasure. Palgrave Macmillan.

Griffiths, M.D. (2012). The use of online methodologies in studying paraphilia: A review. Journal of Behavioral Addictions, 1, 143-150.

Griffiths, M.D. (2013). Eproctophilia in a young adult male: A case study. Archives of Sexual Behavior, 42, 1383-1386.

Haslam, D.W. (2014). Obesity and Sexuality. In Controversies in Obesity (pp. 45-51). London: Springer.

Kyrölä, K. (2011). Adults growing sideways: Feederist pornography and fantasies of infantilism. Lambda Nordica: Tidskrift om homosexualitet, 16(2-3), 128-158.

Monaghan, L. (2005). Big handsome men, bears, and others: Virtual constructions of ‘fat male embodiment’. Body and Society, 11, 81-111.

Murray, S. (2004). Locating aesthetics: Sexing the fat woman. Social Semiotics, 14, 237-247.

Prohaska, A. (2013). Feederism: Transgressive behavior or same old patriarchal sex? International Journal of Social Science Studies, 1(2), 104-112.

Prohaska, A. (2014). Help me get fat! Feederism as communal deviance on the internet. Deviant Behavior, 35(4), 263-274.

Swami, V. & Furnham, A. (2009). Big and beautiful: Attractiveness and health ratings of the female body by male ‘‘fat admirers’’. Archives of Sexual Behavior, 38, 201-208.

Swami, V., & Tovee, M.J. (2006). The influence of body weight on the physical attractiveness preferences of feminist and non-feminist heterosexual women and lesbians. Psychology of Women Quarterly, 30, 252-257.

Swami, V. & Tovee, M.J. (2009). Big beautiful women: the body size preferences of male fat admirers. Journal of Sex Research, 46, 89-96.

Terry, L. L., Suschinsky, K. D., Lalumiere, M. L., & Vasey, P. L. (2012). Feederism: an exaggeration of a normative mate selection preference? Archives of Sexual Behavior, 41(1), 249-260

Terry, L.L. & Vasey, P.L. (2011). Feederism in a woman. Archives of Sexial Behavior, 40, 639-645.

Cheesy does it: An unusual case of sitophilia

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 

Further reading

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

Further reading

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

Blood discussed: A brief look at haematophagia

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

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

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

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

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

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

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

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

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

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

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

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

Further reading

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

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

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

Wikipedia (2013). Blood as food. Located at: http://en.wikipedia.org/wiki/Blood_as_food

Wikipedia (2013). Hematophagy. Located at: http://en.wikipedia.org/wiki/Hematophagy

Let’s get physical: Exercise addiction (revisited)

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.

CASE STUDY

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

Further reading

Allegre, B., Souville, M., Therme, P., & Griffiths, M.D. (2006). Definitions and measures of exercise dependence, Addiction Research and Theory, 14, 631-646.

Allegre, B., Therme, P., & Griffiths, M. D. (2007). Individual factors and the context of physical activity in exercise dependence: A prospective study of ‘ultra-marathoners’. International Journal of Mental Health and Addiction, 5, 233-243.

Berczik, K., Szabó, A., Griffiths, M. D., Kurimay, T., Kun, B., Urbán, R., & Demetrovics, Z. (2012). Exercise addiction: symptoms, diagnosis, epidemiology, and etiology. Substance Use and Misuse, 47, 403-417.

Downs, D. S., Hausenblas, H. A., & Nigg, C. R. (2004). Factorial validity and psychomaetric examination of the Exercise Dependence Scale-Revised. Measurement in Phisical Education and Exercise Science, 8, 183-201.

Griffiths, M. (1997). Exercise addiction: A case study. Addiction Research, 5, 161-168.

Griffiths, M. D., Szabo, A., & Terry, A. (2005). The exercise addiction inventory: a quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39, e30-31.

Hausenblas H. A., & Downs, S. D. (2002a) Exercise dependence: a systematic review. Psychology of Sport Exercise, 3, 89-123.

Hausenblas, H. A., & Downs, S. D. (2002). How much is too much? The development and validation of the exercise dependence scale. Psychology and Health, 17, 387-404.

Mónok, K., Berczik, K., Urbán, R., Szabó, A., Griffiths, M.D., Farkas, J., Magi, A., Eisinger, A., Kurimay, T., Kökönyei, G., Kun, B., Paksi, B. & Demetrovics, Z. (2012). Psychometric properties and concurrent validity of two exercise addiction measures: A population wide study in Hungary. Psychology of Sport and Exercise, 13, 739-746.

Sussman, S., Lisha, N., & Griffiths, M. D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Szabo, A. (2000). Physical activity as a source of psychological dysfunction. In S. J. Biddle, K. R. Fox & S. H. Boutcher (Eds.), Physical Activity and Psychological Well-Being (pp. 130-153). London: Routledge.

Szabo, A., & Griffiths, M. D. (2007). Exercise addiction in British sport science students. International Journal of Mental Health and Addiction, 5, 25-28.

Terry, A., Szabo, A., & Griffiths, M. (2004). The exercise addiction inventory: a new brief screening tool. Addiction Research and Theory, 12, 489-499.

Blood pressures: Interview with a [female] vampire

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.

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

Further reading

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

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

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

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

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

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

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

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

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

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

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

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

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

The weighting game: Gambling with the nation’s health (revisited)

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.

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

Further reading

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.

Bog standard: A brief look at toilet tissue eating

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

Further reading

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

Metal defectives: A brief look at metal eating and acuphagia

In a previous blog I briefly examined pica (an eating behaviour in which individuals eat non-nutritive items or substances such as coal, hair and wood). One thing I was surprised to find out was how many different sub-types of pica there are. For instance, a 2005 review of pica by Dr. L.N. Stiegler in an autism journal listed (in alphabetical order) acuphagia (eating sharp objects), amylophagia (laundry starch), coprophagia (faeces), cautopyreiophagia (burnt matches), foliophagia (leaves, grass), geophagia (sand, clay, dirt), lignophagia (wood, bark, twigs), lithophagia (stones, pebbles), pagophagia (ice, freezer frost), plumbophagia (lead items), tobaccophagia (cigarettes, butts), and trichophagia (hair). Today’s blog examines acuphagia and metal eating (which doesn’t appear to have specific sub-name). Here are a few interesting media stories that caught my eye:

  • Case 1: “Serbian pensioner Branko Crnogorac was rushed to hospital after he attempted to eat a bicycle within three days as part of a bet made by friends.The stuntman, who has already consumed 25,000 light bulbs, 12,000 forks and thousands of vinyl records in a glittering 60-year career, was in a severe condition when doctors attended to him. ‘I almost died,’ said Mr Crnogorac. ’Doctors at the same time found two kilograms of assorted ironware in my stomach, including two gold rings. ‘So after 20 years of eating everything, I’ve realised my digestive system is not as strong as it used to be, so I’ve decided to retire.’ Crnogorac’s obsessive object eating began after a friend recommended he eat sand to calm down an acidic stomach ache. From then on Mr Crnogorac resolved to eat any object in sight. Mr Crnogorac has also managed to eat 2,000 spoons and 2,600 plates”.
  • Case 2: “Doctors in a coastal town in northwestern Peru have rescued the innards of a 38-year-old man by removing 17 metal objects – among them nails, a watch clasp and a knife – that he ate. Luis Zarate was taken to the regional hospital of Trujillo earlier this week by his family after complaining of sharp stomach pains. Doctors took X-rays of his chest that showed his insides littered with screws. ‘There were 17 strange objects found at the level of his stomach and colon’, said Dr. Julio Acevedo, one of the surgeons who operated on Zarate. The black-and-white scans showed Zarate’s skeleton interlaced with things like bolts, barbed-wire and pens. ‘The objects had caused the stomach to expand’ said Acevedo. Doctors said Zarate was mentally ill but it was not clear why he ate the metal”.
  • Case 3: A 40-year-old Ethiopian man is recovering in hospital after surgeons in Addis Ababa removed 222 metallic objects from his stomach.Gazehegn Debebe was admitted to Tibebu General Hospital last week after complaining of continuous vomiting.After intensive investigation, doctors opened his stomach to find an assortment of 15 cm nails, door keys, hair pins, coins and even watch batteries.Doctors at the hospital say it’s incredible that Gazahegn’s stomach could contain all these objects…‘He must have been eating these objects for at least two years, as the wall of his stomach had thickened to accommodate all the inedible objects’ said Dr Samuel.Some of the nails found were 15 cm in length…It is unclear why Gazehegn was eating nails and other objects, but his family say he has a history of mental illness”.
  • Case 4: “47-year old Englishman Allison Johnson [was an] alcoholic burglar with a compulsion to eat silverware, Johnson has had 30 operations to remove strange things from his stomach. In 1992, he had eight forks and the metal sections of a mop head lodged in his body. He has been repeatedly jailed and then released, each time going immediately to a restaurant and ordering lavishly. Unable to pay, he would then tell the owner to call the police, and eat cutlery until they arrived. Johnson’s lawyer said of his client, ‘He finds it hard to eat and obviously has difficulty going to the lavatory”.

After reading these news stories, it got me wondering what academic research had been carried out on people that voluntarily eat metal objects (irrespective of whether the person is mentally ill).One of the earliest papers that I came across was a case study by Dr. K.M. Hambridge and Dr. A. Silverman published in a 1973 issue of the Archives of Disease in Childhood. They described the case of a 2-year-old girl had a 6-month history of pica, that resulted in ‘metal-eating’. She had a poor appetite generally and was diagnosed with a zinc deficiency. When she was one-and-a-half-years old she began to eat small metallic objects (such as keys, the metal trim on carpets, and bits of aluminium foil). She was treated with a dietary zinc supplement and within 3 days, her pica disappeared completely. Papers and other anecdotal evidence from parents demonstrates children eating metallic objects is well documented, although acuphagia in children appears to be very rare (and is potentially fatal). In a 2003 book chapter in the book Child Psychopathology, Dr. L.G. Klinger and colleagues reported that acuphagia has been documented in autistic children, and that this may be possibly due to sensory disturbances.

Acuphagia and metal eating appears to be rarer in adult populations although a number of case studies from around the world have been published over the last decade. For instance, a 2007 paper by Dr. D. Halliday and Dr. F. Iroegbu reported the case of a 22-year old adult Nigerian male (Mr. C.O.) that turned up at hospital complaining of “persistent vomiting after meals, cough, weakness, inability to walk and swelling of the legs and face”. The initial diagnosis was ‘kwashiorkor’ (protein calorie malnutrition) but following an X-ray, the doctors discovered there were metallic objects in his upper abdomen. Following a surgical procedure, a total of 497 metallic objects weighing 1.84 kilograms were found in his stomach (and what was most remarkable was that his stomach was completely in tact). This included 303 two-inch nails, 145 coins, 25 office pins, six razor blades, and 18 sowing needles.Mr. C.O. was referred for psychiatric consultation but denied he had swallowed all the metallic objects (and no-one close to him had ever seen him ingest any metallic objects). Halliday and Iroegbu concluded that in their part of the world, magical arts (i.e., juju) is widely practiced and believed, and that this was the most likely explanation for his illness, triggered by a number of other factors including poverty, isolation, neglect and loneliness.

In 2008, another case was reported in the Indian Journal of Surgery by Dr. P. Kariholu and his colleagues. However, they debated whether their case was acuphagia and/or hyalophagia (the eating of glass materials – a subtype not actually listed in Stiegler’s classification above). In this particular case, a young 20-year old woman presented for treatment with an impacted mass of 18 bangles broken into 55 glass bangle pieces (each measuring 2cm to 7cm) in the stomach as well as few in her small and large bowel. The bangles were successfully removed via surgery.

A short 2007 article in The Medicine Forum by Dr. Saurabh Bansal described the case of a 29-year old male with a history of acuphagia who needed treatment after “accidentally” swallowing a pen. The patient underwent an esophagogastroduodenoscopy (EGD) to remove the pen, and left the hospital six hours after the EGD. Ten days later, the same man returned to the hospital with hematemesis (i.e., vomiting blood). This time he had swallowed a knife and after emergency treatment was sent to the psychiatric facility. Unfortunately no information was provided in relation to the man’s psychiatric assessment.

Most recently, a 2010 paper by Dr. B.T. te Wildt and colleagues in a psychiatric journal reported a case of acuphagia as a disorder of impulse control. They reported the case of a 41-year-old man with intellectual disabilities who required medical treatment after having swallowing around 20 sharp objects. He had also swallowed a glove. The patient claimed that the swallowing of the objects was done to alleviate tension and stress. The authors also wrote that the man’s “aberrant behavior also seemed to serve as a means to exert pressure on psychosocial workers. Other deviations included the pushing of sharp objects under the skin and multiple paraphiliae. As a child, the patient suffered from early psychological and physical traumatization. Both parents were allegedly physically abusive alcoholics”.

Although very few cases of acuphagia have been reported in the medical literature (particularly in adults), most of these suggest that those displaying the symptoms have psychological and/or psychiatric disorders that may be accompanied by some form of learning disability (except – of course – if the behaviour is part of an ‘entertainment’ act).

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

Further reading

Bansal, S. (2007). Acuphagia. The Medicine Forum, 9, Article 23. Available at: http://jdc.jefferson.edu/tmf/vol9/iss1/23

Halliday, D., & Iroegbu, F. (2007). Case report ‘Acuphagia’ – An adult Nigerian who ingested 497 sharp metallic objects. Editorial Advisory Board, 4(2), 54-59.

Hambidge, K.M., & Silverman, A. (1973). Pica with rapid improvement after dietary zinc supplementation. Archives of Disease in Childhood, 48, 567-568.

Kariholu, P. L., Jakareddy, R., Hemanth Kumar, M., Paramesh, K. N., & Pavankumar, N. P. (2008). Pica – A case of acuphagia or hyalophagia?. Indian Journal of Surgery, 70(3), 144-146.

Klinger, L.G., Dawson, G., & Renner, P. (2003). Autistic disorder. In: E.J. Mash & R.A. Barkley (Eds.), Child Psychopathology, 2nd Edition (pp. 409-454). New York: Guilford Press.

Stiegler, L.N. (2005). Understanding pica behavior: A review for clinical and education professionals. Focus on Autism and Other Developmental Disabilities, 20(1), 27-38.

te Wildt, B. T., Tettenborn, C., Schneider, U., Ohlmeier, M. D., Zedler, M., Zakhalev, R. & Krueger, M. (2010). Swallowing foreign bodies as an example of impulse control disorder in a patient with intellectual disabilities: a case report. Psychiatry (Edgmont), 7(9), 34

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