Waste not, want not: A brief overview of coprophagia

One of the most stomach churning behaviours among humans is coprophagia (i.e., the eating of faeces), and has the capacity to generate intense emotional reactions among those witnessing such behaviour. I don’t know about you, but my first visual exposure to human copraphagia was in the 1972 John Waters film Pink Flamingos when the leading “actress” Divine (a transvestite male) ate the freshly produced (and real) excrement from a dog that had just defecated on the pavement. As the narrator states immediately this as happened, Divine is “not only the filthiest person in the world, but is also the world’s filthiest actress”. The arts world is littered with coprophagic references and acts ranging from the detailed descriptions in the Marquis de Sade’s infamous novel The 120 Days of Sodom through to recent films such as The Human Centipede.

Hundreds of years ago, medical doctors used to taste their patients’ faeces as a way to assess their patients health and condition. Such historical actions, while seemingly gross, at least had a functional goal. In contemporary society, coprophagia often occurs among individuals with severe developmental disabilities although for a very small minority, coprophagic acts may occur as part of the sexual paraphilia coprophilia (i.e., sexual arousal and pleasure from faeces).

Copraphagia is a complex behavioural disorder and is commonly regarded as a variant form of pica (i.e., the eating of non-nutritive items or substances), even though there are many health risks associated with it (e.g., intestinal parasites, diarrhea, blood-borne pathogens). Other problems include poor oral hygiene, chronic gingival infection, and salivary gland infections.

A number of medical disorders have been identified that are associated with coprophagia including seizure disorders, cerebral atrophy, and tumours. There are also many psychological and psychiatric disorders associated with coprophagia including mental retardation, alcoholism, severe depression, autism, obsessive-compulsive disorder, Klüver-Bucy syndrome, schizophrenia, fetishes, delirium, and dementia. The psychopathological roots and etiology of coprophagia still remain little known, and much of what has been published academically involves case studies. Furthermore, the prevalence of copraphagia is also unknown but thought to be very rare.

In a 1989 study of 14 elderly coprophagic patients (average age of 71 years) in psychiatric hospitals published in the British Journal of Psychiatry, Ghaziuddin and McDonald reported that nine had senile dementia, two were severely depressed, and one had cerebral atrophy. Three of the 14 were reported has having no cognitive deficits. Although comprising only 14 patients, this is actually one of the largest studies in the area as most published papers consist of case studies.

As mentioned above, copraphagia can on occasion be seen as part of a sexual fetish where the eating of faeces is associated with sexual arousal. In a 1995 issue of the Journal of Sex and Marital Therapy, Dr. T. Wise and Dr. R. Goldberg reported the case of a non-psychotic 47-year old man of normal intelligence who had a fetish for faecal smearing that escalated into coprophagia when combined with alcohol abuse and depression.

In researching this blog, I came across a form of culture bound syndrome called Arctic Hysteria (also known as Piblokto and Pibloktoq) where one of the common symptoms is coprophagia. Culture bound syndromes comprise a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies. Arctic Hysteria only manifests itself in winter among Inuhuit societies living (unsurprisingly) within the Arctic Circle. The condition is characterized by “an abrupt dissociative episode of intense hysteria, frequently followed by convulsive seizures and coma lasting up to 12 hours”. Symptoms can include intense screaming, uncontrolled wild behaviour, depression, coprophagia, and insensitivity to extreme cold”. Some scholars have cast doubt on its existence as a bona fide medical entity, but the association with copraphagia occurs repeatedly.

There is a wide variety of treatments that have been used for coprophagia including behavioural therapy, dietary changes, pharmacotherapy (e.g., tricyclic antidepressants, haloperidol, perospirone), and electro-convulsive therapy. All of these have reported at least partial success but as with research on coprophagia more generally, most treatment papers are based on case studies.

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

Further reading

Beck D.A. & Frohberg, N.R. (2005). Coprophagia in an elderly man: a case report and review of the literature. International Journal of Psychiatry Medicine, 35, 417-427.

Donnellan, C.A. & Playfer, J.R. (1999). A case of coprophagia presenting with sialadenitis. Age and Ageing, 28, 233-234.

Foxx, R. M., & Martin, E. D. (1975). Treatment of scavenging behavior (coprophagy and pica) by overcorrection. Behavior Research and Therapy, 13, 153–162.

Friedin, B.D., & Johnson, H.K. (1979). Treatment of a retarded child’s feces smearing and coprophagic behavior. Journal of Mental Deficiency Research, 23, 55–61.

Ghaziuddin, N. & McDonald, C. (1989). A clinical study of adult coprophagics. British Journal of Psychiatry, 4, 53-54.

Harada, K.I., Yamamoto, K. & Saito, T. (2006). Effective treatment of coprophagia in a patient with schizophrenia with the novel atypical antipsychotic drug perospirone. Pharmacopsychiatry, 39, 113.

Ing, A.D., Roane, H.S. & Veenstra, R.A. (2011). Functional analysis and treatment of coprophagia. Journal of Applied Behavior Analysis. 44, 151–155

Pardini, M., Guida, S. & Gialloreti, L.E. (2010). Aripiprazole Treatment for Coprophagia in Autistic Disorder. Journal Neuropsychiatry and Clinical Neuroscience, 22(4), E33

Wise, T.N. & Goldberg, R.L. (1995). Escalation of a fetish: coprophagia in a nonpsychotic adult of normal intelligence. Journal of Sex and Marital Therapy, 21, 272-275.

Sick note: A (very) brief overview of emetophilia

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

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

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

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

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

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

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

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

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

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

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

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

Further reading

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

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

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

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

Urine demand: A beginner’s guide to urophilia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further reading

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

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

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

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

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

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

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

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

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

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

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

The bite of passion: Vampirism as a sexual paraphilia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further reading

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

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

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

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

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

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

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

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

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

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

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

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

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

Snot machines: Can nose picking be an obsessive-compulsive disorder?

How does it make you feel when you see someone picking their nose and then eating what they have found? Disgust? Contempt? Amused? Whatever your reaction it’s unlikely to be neutral. Nose-picking on the face of it (no pun intended) is probably one of the most under-researched activities given the fact that it is an every day activity for many people and appears to be a universal activity across cultures. It is believed that across many cultures, nose-picking belongs to a set of behaviours considered a private act (such as burping, breaking wind, urinating and defecating).

There is also an element of the activity being mildly taboo despite it being so prevalent. The definition I’ve come across most often in non-academic journals (i.e., on the internet) is that nose-picking is the act of extracting dried nasal mucus (snot) and/or foreign bodies with a finger from the nose. There have been anecdotal reports that people engaging in some sorts of activity appear to be more likely to pick their noses in seemingly public places (drivers stopping at traffic lights or junctions being one example I came across in a blog on nose-picking). But what does the empirical research say about nose-picking?

A paper published on nose picking in the Journal of Clinical Psychiatry (JCP) in the mid-1990s by James Jefferson and Trent Thompson (University of Wisconsin Medical School, USA), reported that 91% of people surveyed in Wisconsin were current nose-pickers (n=254). Three-quarters of the sample thought that “almost everyone else does it”. Five respondents (2%) said they picked their nose for enjoyment, and one person said they found picking their nose sexually stimulating. Two respondents reported that their nose-picking had led to a perforation of the nasal septum. Another two people in the study said they were excessive nose-pickers (with one respondent spending 15-30 minutes a day picking their nose, and the other one claiming they spent 1-2 hours a day picking their nose). It is possible that these two excessive nose-pickers may have been suffering from rhinotellexomania that is characterized as a constant, repetitive and/or pathological picking of the nose and viewed by some as a form of undiagnosed obsessive-compulsive disorder. They also reported the incidence of other associated behaviours. A total of 25% picked their cuticles, 20% picked at skin, 18% bit their fingernails (18%), and 6% pulled out their hair.

More recently (and taking their lead from the earlier study published in the 1995 JCP paper), two psychiatrists – Dr Chittaranjan Andrade and Dr B.S. Srihari (National Institute of Mental Health and Neurosciences in Bangalore, India) – published a study on rhinotillexomania among 200 adolescents in the Journal of Clinical Psychiatry. They reported that adolescents pick their noses about four times a day. They started from the position that any human activity – if carried to excess – could potentially be viewed as a psychiatric disorder. They made reference to earlier case studies in the literature which seemed to indicate that excessive nose-pickers written about affected were psychotic (e.g., Gigliotti & Waring, 1968 – 61-year-old woman with extensive self-mutilation of the inner nose such that a nasal prosthesis and complete upper denture had to be constructed; Akhtar & Hastings 1978 – a 36-year-old male compulsive nose picker, who had life-threatening nosebleeds as a result of excessive nose picking). A more recent case study published by Ronald Caruso and colleagues (State University of New York Health Science Center at Syracuse, USA) presented a case of rhinotillexomania in a woman. They noted:

“Chronic self-mutilation resulting in the loss of body parts is characteristically seen in schizophrenic patients. Such patients can have delusions of parasitic infestation of body parts, may believe the body part to be encumbered by foreign bodies, or may view the body part as no longer a part of themselves. Such behavior, however, may also be manifested by persons who are severely obsessive-compulsive or malingerers… A 53-year-old right-handed woman related a history of compulsive nose picking (rhinotillexomania) of the right nasal cavity since age 10. She could not control her compulsion, which involved removing recurrent intranasal crusts. This condition persisted while in the care of a psychiatrist… Therapy was instituted in an effort to disrupt the cycle of digital trauma, mucus production, and crusting. This included behavior modification and supportive rhinologic care with nasal spray, crust suction, and medication. Early follow-up showed improvement”

They noted that the psychiatric literature has recognized that “rhinotillexomania is a common, benign habit in children and adults” but that in rare cases it can become a serious affliction advancing to significant self-injury.

Andrade and Srihari’s main findings were that (i) 96% had picked their nose, (ii) 80% used their fingers to pick their nose, (iii) half picked their noses four or more times a day, (iv) 7% picked their noses 20 or more times a day, (v) over 50% picked their noses to unclog nasal passages, to relieve discomfort, or to relieve itching, (vi) 11% picked their nose for cosmetic reasons, and (vii) 11% picked their noses for pleasure. They also observed that based on their sample, nose-picking practices were the same across all social classes.

Much less is known about the act of eating the extracted contents directly from the nose (known as mucophagy). A case report dating back to 1966 by Sidney Tacharow on copraphagia (eating faeces) also examined the eating of other bodily substances. The author claimed that the reason people ate nasal debris was because they found it “tasty”. In the study by Jefferson and Thompson, it was reported that 8% of their respondent admitted to eating their nasal content (but there was no reason given as to why they did it). The study by Andrade and Srihari’s reported that 4.5% of their participants ate their nasal debris.

I did a literature search looking for academic papers on snot eating snot and only came up with only one by Maria Jesus Portalain – a 2007 book chapter entitled “Eating snot – Socially unacceptable but common: Why?” in an edited book collection called “Consuming the inedible: neglected dimensions of food choice” (which also had chapters on topics such as geophagia and cannibalism). She questioned to what extent snot could be classed as edible? As she noted, the composition of snot was water (95%), glycoprotein (2%), other proteins (1%), immunoglobin (1%), lactoferrin (trace), lysozyme (trace), and lipids (trace). She observed that the eating of snot could be studied from a number of different scientific disciplines but it was only psychologists that had ever studied it. She argued that nasal mucus was socially accepted but eating it was not. In preparation of writing her chapter, she asked a small group of adults if they ate they ate their snot and they all vehemently said they didn’t. She then asked the same people if when they kissed their partner they put their tongue in their partner’s mouths. It was a ‘yes’ all around. She then posed the question why consuming your partner’s saliva was better than eating your own snot?

In February 2008, an Austrian lung specialist (Dr Friedrich Bischinger) was reported as saying that picking your nose and eating it was good for you. He claimed that people who pick their noses with their fingers were healthy, happier and probably better in tune with their bodies than those who didn’t. He was reported as saying:

“With the finger you can get to places you just can’t reach with a handkerchief, keeping your nose far cleaner. And eating the dry remains of what you pull out is a great way of strengthening the body’s immune system. Medically it makes great sense and is a perfectly natural thing to do. In terms of the immune system the nose is a filter in which a great deal of bacteria are collected, and when this mixture arrives in the intestines it works just like a medicine. Modern medicine is constantly trying to do the same thing through far more complicated methods. People who pick their nose and eat it get a natural boost to their immune system for free. I would recommend a new approach where children are encouraged to pick their nose. It is a completely natural response and medically a good idea as well. Children happily pick their noses, yet by the time they have become adults they have stopped under pressure from a society that has branded it disgusting and anti social”

He went on to suggest that if anyone was worried about what other people think, they should pick their noses privately if they want to get the benefits. Despite the alleged benefits of nose picking I will leave you with a 2002 case reported by Dr L.F. Fontenelle and colleagues (Federal University of Rio de Janeiro, Brazil) who described a person with rhinotillexomania that may have been secondary to body dysmorphic disorder (BDD). The man in question developed a self-destructive habit of pulling and severely scraping hairs and nasal debris out of his nose. The authors proposed the term rhinotrichotillomania to emphasize the overlapping between trichotillomania (compulsive hair pulling) and rhinotillexomania (compulsive nose picking). The main motivation behind the man’s actions was a distressing preoccupation with an imaginary defect in his appearance (a core characteristic of BDD). The authors suggested that certain features of trichotillomania, rhinotillexomania, and BDD may in some circumstances overlap and produce serious clinical consequences.

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

Further reading

Akhtar, S. & Hastings, B.W. (1978). Life threatening self-mutilation of the nose. Journal of Clinical Psychiatry, 39, 676-677.

Andrade, C. & Srihari, B.S. (2001). A preliminary survey of rhinotillexomania in an adolescent sample. Journal of Clinical Psychiatry, 62, 426-31.

Caruso, R.D. Sherry, R.G., Rosenbaum, A.E., Joy, S.E., Chang, J.K. & Sanford, D.M. (1997). Self-induced ethmoidectomy from rhinotillexomania. American Journal of Neuroradiology 18, 1949-1950.

Fontenelle, L.F. Mendlowicz, M.V., Mussi, T.C., Marques, C. & Versiani, M. (2002). The man with the purple nostrils: a case of rhinotrichotillomania secondary to body dysmorphic disorder. Acta Psychiatrica Scandinavica, 106, 464-466.

Gigliotti, R. & Waring, H.G. (1968). Self-inflicted destruction of nose and palate: Report of case. Journal of the American Dental Association, 76, 593-596.

Jefferson, J.W. & Thompson, T.D. (1995). Rhinotillexomania: Psychiatric disorder of habit?  Journal of Clinical Psychology, 56 (2), 56-59.

Portalain, M.J. (2007). Eating snot – Socially unacceptable but common: Why?” In J. MacClancy, J. Henry & H. Macbeth (Eds.), Consuming the inedible: neglected dimensions of food choice. New York: Berghahn Books.

Tarachow, S. (1966). Coprophagia and allied phenomena. Journal of the American Psychoanalytic Association, 14, 685-699.

Turn the eater on: Fat fetishes and feederism

Many years ago when I was just entering my teens (well, 1979 since you ask), I heard a song by Adam and the Ants called ‘Fat Fun’ which at the time completely passed me by that it was all about fat fetishes. I should have guessed given that so many songs written by Adam Ant at the time were about fetishes and paraphilias (something that I have written about in an essays at length elsewhere (you can check them out in various places here and there).

Over the last few years, fat fetishism and fat admiration have come into more into the public domain through national press and television documentaries (I was interviewed by The Times on the topic back in June 2010)

Fat fetishists – mostly heterosexual and sometimes colloquially referred to as ‘chubby chasers’ – have an overwhelming (and often exclusive) sexual attraction towards very obese individuals of the opposite sex. (As a number of researchers point out, there is no widely held consensus in defining a fat admirer (FA), but the term is typically used in relation to individuals who find attractive someone considered clinically overweight). However, a recent paper by Dr Lee Monaghan (University of Limerick, Ireland) also noted and described aspects of the small gay fat admiration community through the use of qualitative data he collected online.

Fat fetishism also includes both ‘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. This may not only involve eating more food but also engaging in sedentary activities that leave the feedee immobile. Some fat admirers may also derive pleasure from very specific parts of the body becoming fatter. A recent paper by Dr Lesley Terry and Dr Paul Vasey (both at the University of Lethbridge, Canada) in the Archives of Sexual Behavior, also claim that feedees are individuals who become sexually aroused by eating, being fed, and the idea or act of gaining weight.

Even if a fat admirer does not have direct sexual access to someone grossly overweight, there are other activities that fat admirers can encourage their sexual partners to engage in such as ‘padding’ (where individuals wear padded or layered clothing in a way that the person appears to have a distended abdomen) and inflation (where individuals inflate their abdomen with air or liquid so their abdomen is distended).

There has been a lot of psychological research showing that attractiveness of women is related to both low body mass index (BMI) and low waist-to-hip ratio (WHR). However, there has been a great deal of debate the universality of the findings and there is a lot of research that body shape attractiveness is determined by other factors including cross-cultural differences and gender-role stereotyping. There has also been research on physical attractiveness among ‘subcultures’ such as those people with eating disorders or in relation to sexual orientation. For instance, a study by Dr Viren Swami (University of Westminster, UK) and Dr Martin Tovee (University of Newcastle, UK) found that lesbians appear to idealize a heavier body weight in a potential partner than do heterosexual women or men.

One of these relatively unexplored ‘subcultures’ is the FA community. A study by Dr Viren Swami (by this time at the University of Liverpool, UK) and Professor Adrian Furnham (University College London, UK) and published in the Archives of Sexual Behavior (2009), examined the body weight WHR preferences of 56 heterosexual ‘fat admirers’. They claimed that the “relative scarcity of studies on the preferences of FAs can probably be traced back to the misperception that it is inconceivable that an individual could be attracted to obese others or that such a preference is somehow ‘’deviant’”. Unsurprisingly, their study – which was the first published on notions of attractiveness within the FA community – reported that FAs preferred heavyweight individuals and rated those individuals with high WHRs as the most attractive. The results predictably suggest that heterosexual male FAs hold very different ideals relating to attractiveness when compared with heterosexual men from the general population. Although some of the participants were fat themselves, there was no difference between these individuals and those FAs who were not overweight. The authors conclude that:

“It seems plausible that male FA is paraphilic in the sense of it being a non-mainstream sexual practice without necessarily implying dysfunction or deviance. For instance, it may be that hunger or food was involved in the behavioral imprinting of a fat fetish in early childhood, a hypothesis favored by some psychoanalysts…A related theory also based on the principles of behavioral imprinting argues that when young men masturbate, the objects that are frequently nearby at the time of masturbation become objects of arousal in the future. The individual is thus associating the object with sexual orgasm, and this may include either eroticized images of overweight individuals, food, and so on” (p.206).

It is also worth noting that in the Journal of Sex Research, Dr Swami repeated the study comparing FAs with a control group of non-FAs and found the same results. Despite these studies, there is still little empirical research on fat admirers and feederism. The recent paper by Dr Terry and Dr Vasey reported the case study of a 30-year old female feedee (‘Lisa’).

At the time of the study, Lisa was 30 years of age, married and Caucasian. She was recruited by the researchers from a feederism website (FantasyFeeder.com). By age 13 years (at 5 feet 11 inches tall) she was mildly preoccupied with her weight. She weighed 120-130 lbs and had BMI of 16-18 (i.e., underweight). However. Like many girls, she viewed herself as fat and became self-conscious about her hips, thighs, and belly. She claimed to experience sexual thoughts about weight gain and fat from a very young age. Because of her sexual fantasies about fat women during adolescence, she experienced some confusion about her sexual orientation (but deemed herself heterosexual).

As an adult, Lisa said she was still sexually aroused in response to fat women but that it was limited to visual images found on the internet. Her ideal website would be where there were several pictures of the same woman getting fatter over time (and which she would masturbate over). Lisa also fantasized about being forced to gain weight by a dominant male who would became sexually aroused by making her gain weight. She also reported that all of her orgasms involve fantasizing about some form of feederism and that sometimes all she needs to reach orgasm is to fantasize about being a little bit heavier. Although she has actively engaged in weight gain for a four-month period in 2008, she has never been in a feedee/feeder relationship (as she doesn’t want the negative health consequences of becoming extremely overweight). She also reported her sexual arousal had significantly declined after the weight gain period.

In their discussion of Lisa’s case, Terry and Vasey made the point that as with many paraphilias, her pattern of sexual arousal was characterized by intense and repetitive sexual urges, fantasies, and behaviours involving unusual activities (i.e., the intense focus on eroticizing body fat). Terry and Vasey also questioned whether Lisa’s behaviour represented a form of morphophilia (i.e., peak erotic focus on a particular body characteristic – in this case body fat). They also speculated that some of the behaviour was sexually masochistic and that this supported their view that feederism had paraphilic elements (although Lisa reported that masochistic behaviours generally repulsed her). As with any case study, it may not be representative of the entire feederism community. Terry and Vasey also assert that more research needs to consider if, and how, feederism is taxonomically distinct from the various forms of morphophilia.

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

Further reading

Griffiths, M.D (1999). Adam Ant: sex and perversion for teenyboppers. Headpress: The Journal of Sex, Death and Religion, 19, 116-119.

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.

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

Pica boom? A beginner’s guide to pica

Pica is an eating disorder that has been documented in the psychological literature for hundreds of years and refers to a behaviour in which individuals eat non-nutritive items or substances (such as coal, hair and wood). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines pica as “the persistent eating of nonnutritive substances for a period of at least one month, without an association with an aversion to food”. Therefore, one-off instances of eating non-nutritious items would not constitute pica. Children who occasionally eat items like crayons are rarely diagnosed as having pica. Pica comes from a Latin word for the magpie bird (known for its strange eating behaviours).

The prevalence rates of pica depend on which patient populations have been studied. Prevalence estimates are also skewed by the fact that many people suffering from pica are embarrassed about the behaviour and may not tell anyone and/or seek medial treatment. However, it is well established that pica is more prevalent in children, pregnant women, adults from lower socioeconomic classes, and children with developmental disabilities (such as autism). The incidence of pica is also higher amongst those suffering from family-related stress. Although pica can be a symptom of anaemia (i.e., iron deficiency) and other chemical imbalances, research has shown it is actually more common among those who have normal iron levels.

Prevalence rates of pica have range anywhere between 0.02% and 74% depending on the study and population studied. For instance, studies have reported pica prevalence rates of:

• 0.02% in Danish pregnant women
• 8% in US black pregnant women (pagophagia)
• 9% in Saudi Arabian pregnant women
• 26.5% in Tanzanian pregnant women (geophagia)
• 31% of Californian Mexican pregnant women
• 44% of Mexican pregnant women
• 50% of Nigerian pregnant women
• 74% in Kenyan pregnant women
• 44% in French anaemic patients (vs. 9% matched controls)
• 64% in Turkish anaemic patients (vs. 17% controls)
• 22%-26% in mentally retarded adults
• 34% in sickle cell disease patients

The Danish figure from a study led by Dr Tina Mikkelsen (University of Southern Denmark) is likely to be the most accurate as it was carried out on a sample of 100,000 pregnant Danish women and only 14 of the total sample reported that they had pica. The authors concluded that in privileged populations, pica is more a myth than a reality.

Despite increased research in the area, there has been no definitive explanation as to why some people consume such substances as hair (trichophagia), ice (pagophagia – which I briefly examined in a previous blog), soil/clay (geophagia), wood (xylophagia), stones (lithophagia), glass (hyalophagia), plumbophagia (lead paint chips), or laundry (uncooked) starch (amylophagia). Dr. Ella Lacey (Southern Illinois University) also listed many other non-food substances that pica sufferers may eat that don’t have specific names such as those people who eat paper, balloons, grass, soap, cotton wool, and cigarette butts. Pica is a widespread practice throughout Africa and India. It has also been reported in Australia, Canada, Israel, Iran, Uganda, Jamaica and various European countries. A recent review on pica led by Dr Sera Young (University of California, USA) noted that geophagia is the most common type of pica described in the psychological and medical literature. They also noted that:

• Geophagics frequently eat other non-food stuffs.
• Those who eat more manufactured substances say they use them as a replacement for earth, either because the desired soil is unavailable or socially unacceptable
• Bar the eating of ice, most pica substances are absorptive in the dry state and all easily absorb moisture.
• Pica substances are typically craved with great intensity or ‘‘devouring passion’’

A variety of conditions are known to cause some types of pica including mineral deficiencies, hookworm infection (parasitic infection in the small intestine), coeliac disease (an autoimmune disorder of the small intestine) and Kleine-Levin Syndrome (also known as Sleeping Beauty Syndrome, a neurological disorder characterized by recurring periods of excessive amounts of sleeping and eating). Interestingly, there are culture-specific cases where pica is not related to psychopathological disorders or deficiencies. For instance, black women in Georgia (USA) are known to eat kaolin (white dirt that is actually a clay mineral) – a so-called “culture-bound syndrome” (i.e., a recognizable combination of psychiatric and somatic symptoms that are only within a specific culture or society).

Some pica type disorders may be part of a wider psychiatric condition (such as schizophrenia) and/or may be part of a sexual paraphilia such as the small numbers of people who engage in coprophagia (eating faces) as part of coprophilia and people who engage in urophagia (drinking urine) as part of urophilia. If the primary focus for eating the item or substance was sexual, it would be more likely diagnosed as a sexual paraphila rather than pica. However, many of those with pica claim to love the taste, texture and/or smell of the things they eat. Some studies have suggested an association between pica and addictive behaviors. Others suggest pica is on the obsessive-compulsive disorder (OCD) spectrum of diseases. For instance, a study based on pica case studies by Dr Dan Stein and colleagues (a the University of Stellenbosch, South Africa) came to the conclusion that (based on their case studies), pica may be a symptom of OCD, and that pica may be phenomenologically reminiscent of an impulse control disorder.

For many people, pica is not dangerous but for some there may be complications including (i) parasitic infections (such as geophagics eating soil or copraphagics eating faeces), (ii) internal bodily obstruction (e.g., such as tricophagics getting hair stuck in their intestines), (iii) toxic reactions (e.g., such as autistic children getting lead poisoning from eating painted plaster), (iv) excessive caloric intake (such as that occurring with starch cravings), (v) dental injuries and infections, and (vi) nutritional deficiencies.

As Dr. Lacey concluded: “Pica appears to be a complex behavior that requires deliberate study rather than application of ex post facto single cause theories. Although such theories may motivate any given study of pica, it should be apparent that any single cause model will likely offer only a limited explanation of such diverse practices as have been described in the literature through case reports,’ research studies, and literature ‘reviews of various clinical and applied disciplines”

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

Further reading

al-Kanhal, M.A., & Bani, I.A. (1995). Food habits during pregnancy among Saudi women. International Journal for Vitamin and Nutrition Research, 65, 206-210.

Ashworth, M., Hirdes, J.P. & Martin, L. (2008). The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Research in Developmental Disabilities, 30, 512-520.

Danford, D.E. & Huber, A.M. (1982). Pica among mentally retarded adults. American Journal of Mental Deficiency, 87, 141-146.

Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemade, U.J. et al (1994). Pica in an urban environment. Journal of Nutrition, 124(6 Suppl): 954S-962S.

Kettaneh, A., Eclache, V., Fain, O., Sontag, C., Uzan, M. Carbillon, Stirnemann, J. & Thomas, M. (2005). Pica and food craving in patients with iron-deficiency anemia: A case-control study in France. American Journal of Medicine, 118, 185-188

Lacey, E. (1990). Broadening the perspective of pica: Literature review. Public Health Reports, 105, 29-35.

López, L.B., Ortega Soler, C.R. & de Portela, M.L. (2004). Pica during pregnancy: A frequently underestimated problem. Archivos latinoamericanos de nutricion, 54, 17-24.

Mikkelson, T.B., Andersen, A.M. & Olsen, S.F. (2006). Pica in pregnancy in a privileged population: myth or reality. Acta Obstetricia et Gynecologica Scandinavica, 85, 1265-1266.

Ngozi, P.O. (2008). Pica practices of pregnant women in Nairobi, Kenya. East African Medical Journal, 85(2), 72-79.

Nyaruhucha, C.N. (2009). Food cravings, aversions and pica among pregnant women in Dar es Salaam, Tanzania. Tanzania Journal of Health Research, 11(1), 29–34.

Rose, E.A., Porcerelli, J.H, & Anne Neale, A.V. (2000). Pica: Common but commonly missed. Journal of the American Board of Family Practice, 13, 353-358.

Simpson, E., Mull, J.D., Longley, E., & East, J. (2000). Pica during pregnancy in low-income women born in Mexico. Western Journal of Medicine, 173, 20-24.

Smulian, J.C., Motiwala, S. & Sigman, R.K. (1995). Pica in a rural obstetric population. Southern Medical Journal, 88, 1236–1240.

Stein, D.J., Bouwer, C. & van Heerden, B. (1996). Pica and the obsessive- compulsive spectrum disorders. South African Medical Journal, 86, 1586-1592.

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.