Fame in desire: A brief look at celebriphilia

In a previous blogs I have examined both Celebrity Worship Syndrome and whether fame can be addictive. Another behaviour allied to both of these is celebriphilia. There has been no scientific research on celebriphilia and I have only come across a few passing references to it in academic texts. In his 2009 book Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices, Dr Anil Aggrawal describes it as a sexual paraphilia where a “pathological desire to have sex with a celebrity”. The online Medical Dictionary is slightly different and defines celebriphilia as “an intense desire to have a romantic relationship with a celebrity” (and is therefore slightly different is the focus on this second definition is romance rather than sex, although there is an implicit assumption that having romantic relationship would involve sex). Finally, the only other definition that I have come across is in the online Nation Master encyclopedia that was a bit more padded out and claimed that:

“Celebriphilia is the sexual fetishism and obsession with sex with a celebrity or famous person. Celebriphiliacs may stalk these celebrities and either observe them for sexual pleasure voyeuristically or try and approach them and have sex with them. Some may simply masturbate to images of them”

Despite this more in-depth definition, it actually complicates matters as it brings in other behaviours such as voyeurism and stalking that are separate entities in and of themselves. As far as I can tell, the first reference to ‘celebriphilia’ appeared in an article written by journalists Benjamin Svetkey and Allison Hope Weiner for Entertainment Weekly. Their article was about Bonnie Lee Bakley, the wife of American actor Robert Blake (star of shows like Baretta and films such as In Cold Blood), who was shot in 2001 (May 4) while sitting outside a Los Angeles restaurant in Blake’s car. (Blake was eventually charged with his wife’s murder but was found not guilty. The murder remains officially unsolved although Bakley’s grown-up children from previous relationships took out a civil suit on Blake and was later found guilty of wrongful death).

The focus of the article by Svetkey and Weiner was Bakley’s celebriphilia and her ‘celebrity obsession’ (more specifically, her long-term history of pursuing relationships with celebrities). Bakley’s close friends all stated that her aim in life was to marry someone famous and all of her actions were geared around achieving this goal. Bakley was quoted as saying “being around celebrities makes you feel better than other people”. Her pursuing of celebrities began in 1990 when she became obsessed with wanting to marry rock ‘n’ roll singer Jerry Lee Lewis. She even moved to Memphis where Lewis was living, met him, and befriended Lewis’ sister as a way of getting closer to him. Bakley may have had a brief sexual relationship with Lewis, and in 1993 she gave birth to a daughter and claimed Lewis was the father (and even went as far as to name the baby Jeri Lee). Paternity tests later proved that Lewis was not the father of Bakley’s daughter. Following a move from Memphis to California, she continued her celebrity obsession by pursuing many different celebrities including actor Gary Busey, singer-songwriter and guitarist Chuck Berry, singer Frankie Valli, actor Robert De Niro, singer-songwriter Lou Christie, publisher Larry Flynt, entertainer Dean Martin, and musician Prince, before having a relationship with Marlon Brando’s son, Christian (following his release from prison in 1996).

It was in 1999, that Bakley met American actor Robert Blake while still dating Brando. She became pregnant again (telling both Blake and Brando that they were the father of the baby). She believed Brando was the father of the daughter she gave birth to (naming the child Christian Shannon Brando). However, later paternity tests showed it was Blake who was the father (and the baby was then re-named Rose). In November 2000, Bakley and Blake married (and Blake became Bakley’s tenth [!!!] husband). When I first read about Bakley’s attempts to have a relationship with someone famous, the first words that sprang to mind was ‘groupie’ and ‘stalker’. However, the article by Svetkey and Weiner specifically stated that:

“People who attempt to make themselves ”feel better” by romantically pursuing the famous [are] not groupies: Groupies are merely overzealous, oversexed fans. They’re not stalkers, either. Bakley’s relationship with Blake wasn’t imaginary…nor is she known to have ever threatened him with physical harm. And although her past was hardly squeaky-clean…she wasn’t simply a grifter. What Bakley pursued with meticulous and methodical precision wasn’t so much cash as cachet, the reflected glory of being with a star. Any star would do — even one like Blake, who hasn’t shone for the better part of a decade. Unlike stalkers and groupies, people like Bakley generally don’t develop crushes on the stars they pursue — it’s fame itself that flames their desires, regardless of whom it’s attached to. Sometimes they don’t even seem to like those they’re chasing. While Bakley was attempting a relationship with Blake, for instance, she was also apparently involved with Marlon Brando’s son Christian”.

Most of the famous people that she pursued most actively (i.e., Blake, Brando, Lewis) had careers that were on the wane. She chose people that wanted validation that they were still famous. Both Bakley and the ‘stars’ she chased appeared to be yearning validation, attention and wanting to be perceived as special. An American psychotherapist – Donald Fleming – was interviewed for the article by Svetkey and Weiner. He speculated about celebriphiles:

”Often these people have serious identity problems. They lack a centered sense of self. They’re usually people that have not developed any particular skills or abilities in life. They never developed out of their grandiose childhood wishes and fantasies to be important. The only way they can feel important or special or unique is through famous people being part of their life…People who follow stars often have the obsessive-compulsive trait. They can fool almost anybody. They become so acute at reading how to meet another person’s needs that they can pick up on their vulnerabilities and play them like a violin”.

Dr. David Giles who wrote one of the best books on the psychology of fame – Illusions of Immortality: A Psychology of Fame and Celebrity – explains the relationships that people have with celebrities as a parasocial interaction:

”One of the things about fame is how incredibly new it is to human experience. It started with mass communication, which is only about 100 years old. And the speed with which it’s developed – radio and then TV – has been astonishing. In an evolutionary sense, we may not have caught up with the phenomenon of fame as a species”.

Celebrity (and therefore celebriphilia) is as Dr. Giles would argue a completely modern, man-made phenomenon. In typical journalese, Svetkey and Weiner wrote that celebrity has “been injected into the cultural bloodstream like an untested drug – with a similar rush of disorienting results”. They also speculate about other people that display celebriphilia:

“Courtney Love may have once suffered a touch of it. (‘Become friends with Michael Stipe’, Kurt Cobain’s widow supposedly jotted in a journal years ago, mapping her road to fame)…And certainly Whitney Walton – known around Hollywood as the mysterious ‘Miranda’ – has something like it. She became infamous for charming her way into telephone friendships with Billy Joel, Warren Beatty, Quincy Jones, Richard Gere, and…other celebrities [including] Robert De Niro”.

As noted above, there has been no empirical research on celebriphilia unless you include the small amount of research on ‘celebrity stalking’ (although very few academics who have written on the topic use the word ‘celebriphilia’). However, there are a few exceptions. For instance, Dr. Brian Spitzberg and Dr. Michelle Cadiz wrote a paper on the media construction of stalking stereotypes and described one of the types as ‘stalking as celebriphilia’ in a 2002 issue of the Journal of Criminal Justice and Popular Culture (although the authors didn’t actually define what celebriphilia was in this context). In a 2006 book (Constructing Crime: Perspectives on Making News and Social Problems) edited by Dr. Victor Kappeler and Dr. Gary Potter, the authors briefly noted (in what seems a follow on from the paper by Spitzberg and Cadiz) that “media reports eventually moved away from a dominant image of stalkers as exclusively experiencing ‘celebriphilia’”.

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.

Giles, D. (2000). Illusions of Immortality: A Psychology of Fame and Celebrity. London: Palgrave Macmillan.

Kappeler, V.E. & Gary W. Potter, G.W. (2006). Constructing Crime: Perspectives on Making News and Social Problems. Prospect Heights, IL: Waveland Press.

King, G. (2011). Who murdered Bonny Lee Bakley? (part 7: Bony the celebriphiliac). Crime Library, Located at: http://www.trutv.com/library/crime/notorious_murders/family/bakley/7.html

Medical Dictionary (2012). Celebriphilia. Located at: http://medical-dictionary.thefreedictionary.com/Celebriphilia

Nation Master (2012). Celebriphilia. Located at: http://www.nationmaster.com/encyclopedia/Celebriphilia

Spitsberg, B.H. & Cadiz, M. (2002). The media construction of stalking stereotypes. Journal of Criminal Justice and Popular Culture, 9(3), 128-149.

Svetkey, B. & Weiner, A.H. (2001). Dangerous game. Entertainment Weekly, June 22. Located at: http://www.ew.com/ew/article/0,,256019,00.html

Wiktionary (2012). Citations: Celebriphilia. Located at: http://en.wiktionary.org/wiki/Citations:celebriphilia

Banned aid? A brief guide to compulsive helping

Back in the early 2000s, I (and one of my colleagues, Dr. Michael Larkin) carried out some research at the Promis addiction clinic down in Kent. We were researching people’s phenomenological experiences of addiction, and our interviews with the addicts receiving treatment were really helpful in the writing of what I personally thought were some really interesting papers (see ‘Further reading’ below). However, what interested me even more were the conversations I had with the clinic’s Director, Dr, Robert Lefever who told me of his interest and research into ‘compulsive helping’. Dr. Lefever has written a number of articles online about compulsive helping. In one of them he began by stating:

“Of all the addictive behaviours those surrounding relationships like sex and love addiction, relationship addiction or compulsive helping can be the most difficult to understand. This is further hindered by the confusing terminology used to describe it. Just as addiction means as many different things to as many people so do terms like co-dependency. We have tried to help clarify the situation by using different terms for different behaviours. Where people are addicted to someone they have a relationship with we call it relationship addiction, where people are addicted to helping others with their problems we call it compulsive helping”.

Dr. Lefever says that by giving these behaviours descriptive titles (like ‘compulsive helping’ and ‘relationship addiction’) help the affected person to identify the specific behaviour that they are actually addicted to. He also argues that such labels help the affected person relaise that the person responsible for the addictive behaviour is the individual and not someone or something else. However, Dr. Lefever is the first to admit that “the concept of compulsive helping can be particularly difficult to get one’s head around”.

Obviously not all helping is harmful but Lefever distinguishes between ‘caring’ (which he views as healthy) and caretaking (which he views as unhealthy). Compulsive helping occurs when the ‘caretaker’ (rather than a carer) continually takes on the responsibilities of someone else (very often a person who they love), and in essence runs that person’s life for them. Compulsive helpers often help other people that have an addiction (such as an alcoholic or a gambling addict) but Lefever claims that compulsive helpers can also end up compulsively helping people that doesn’t have problems themselves. (However, those without a problem are far more likely to notice compulsive helping behaviour in other people if they feel it is significantly and continually interfering in their day-to-day life and business). More specifically:

“Caring is lovely and healthy. I would never wish to change that characteristic in anyone. Caretaking however, is over-caring for someone, taking on the other person’s responsibilities for themselves and not allowing the other person to have the consequences of his or her behaviour…Helping is loving. Compulsive helping is destructive of both self and the other person. It is destructive of my own life and destructive of the person whom I am trying to compulsively help. That is not what I would call a loving action”.

Another short article on ‘compulsive helping’ by Rochelle Craig on her Piece By Piece Recovery website has a slightly different take and notes that:

“Compulsive Helping is when the individual finds it impossible to say no each and every time they are asked. A compulsive helper will always help regardless of what the situation is whether it is convenient for them or not. This can result in the compulsive helper building up resentment against the other person or persons and feeling like a doormat. When this happens the compulsive helper begins to resent being asked”

Like Dr. Lefever, Rochelle Craig believes that compulsive helpers take on too much responsibility, and therefore take away responsibility away from other people. Craig is adamant that people should examine their motivation for their helping behaviour to assess the extent to which it is helpful. If the act of helping others is a continual source of gaining self-worth, it may be indicative of compulsive helping. Other signs of compulsive helping is carrying on helping even if it is putting one’s own health, job, and/or other relationships at risk, Craig asserts that:

“It is important to remember that we are talking about addictive behaviour, we are talking about extremes, and we are talking about situations where the compulsive helper is so absorbed with helping others that they lose their own identity. Recovery is about self-discovery, self-improvement and building on self-esteem without relying on constantly helping others. It is about self-care first and everyone else second! Recovery is about recognising the difference between compulsive helping and genuine acts of kindness and most importantly it is learning to say no!”

In another (different) article on compulsive helping, Dr. Lefever refers to ‘compulsive helping’ as ‘co-dependency’ and claims that compulsive helping “is the most perverse, widespread and destructive of all addictive or compulsive behaviours” and the ‘need to be needed’. In fact Dr. Lefever claims that:

“Behind any addict of any kind will be a compulsive helper, or a bunch of them, taking responsibility for them. The compulsive helpers try to solve problems and ferret out information on causes and treatments. They give incessant advice and generally get in the way of addicts having any chance of learning or doing things for themselves – which, ultimately, are the only things that are going to help. Those of us who are afflicted by it go out of our way to give uninvited help. We want to feel useful and constructively helpful. These are admirable characteristics. But they can be very destructive when they are applied without thought to the consequences…When people have too much done for them, they fail to develop their own skills. They become part of the dependency culture”.

Dr. Lefever and psychologists at the University of Kent have published a number of empirical studies on addiction including compulsive helping. In a study led by Professor Geoffrey Stephenson and published in a 1995 issue of the journal Addiction Research, the researchers evaluated addiction in 16 behavioural areas on 471 patients (using 191 male addicts and 281 female admitted to Lefever’s Promis Recovery Centre). The addicted patients’ questionnaires were subjected to a factor analysis and results showed there to be two fundamentally different types of addiction labeled as ‘nurturance’ and ‘hedonism’. ‘Nurturance’ included caffeine, work, exploitative relationships (submissive), shopping, exercise, food bingeing, food starving and compulsive helping. ‘Hedonism’ included alcohol, nicotine, recreational drugs, gambling, exploitative relationships (dominant), sex, and prescription drugs.

A follow-up study published in 2004 by Stephenson and Lefever in the journal Addictive Behaviors, confirmed these earlier results but also suggested that ‘hedonism’ could further be divided into a ‘drug use’ factor and an ‘interpersonal dominance’ factor. The nurturance addictions comprised of both ‘self-regarding’ and ‘other-regarding’ factors. A more recent study in a 2010 issue of Addictive Behaviors by Dr. Vance MacLaren and Dr. Lisa Best confirmed the results among a student population (n=938). Despite this empirical research, it should be remembered that all of the data on compulsive helping has been done using the instrument that Lefever and his colleagues developed. There’s certainly a need for research to be carried out with instruments that weren’t developed and/or carried out by the people who have a vested interest in the ‘compulsive helping’ construct.

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

Further reading

Craig, R. (2012). Compulsive helping. Located at: http://www.piecebypiecerecovery.co.uk/index.php?pageid=8

Griffiths, M.D. & Larkin, M. (2004). Conceptualizing addiction: The case for a ‘complex systems’ account. Addiction Research and Theory, 12, 99-102.

Haylett, S., Stephenson, G.M. & Haylett, S. (2004). Covariation in addictive behaviours: A study of addictive orientations using the Shorter PROMIS Questionnaire. Addictive Behaviors, 29, 61-71.

Larkin, M. & Griffiths, M.D. (2002).  Experiences of addiction and recovery: The case for subjective accounts. Addiction Research and Theory, 10, 281-311.

Larkin, M. & Griffiths, M.D. (2004). Dangerous sports and recreational drug-use: Rationalising and contextualising risk. Journal of Community and Applied Social Psychology, 14, 215-232.

Larkin, M., Wood, R.T.A. & Griffiths, M.D. (2006). Towards addiction as relationship. Addiction Research and Theory, 14, 207-215.

Lefever, R. (2012). Compulsive helping. Located at: http://promis.co.uk/addiction-info/addiction/compulsive-behaviours/

Lefever, R. (2012). Compulsive helping. Located at: http://www.doctor-robert.com/compulsive-helping/

Maclaren, V.V. & Best, L.A. (2010). Multiple addictive behaviors in young adults: Student norms for the Shorter PROMIS Questionnaire. Addictive Behaviors, 35, 252-255.

Stephenson, G.M., Maggi, P., Lefever, R.M.H. & Morojele, N.K. (1995). Excessive Behaviours: An Archival Study of Behavioural Tendencies reported by 471 patients admitted to an addiction treatment centre. Addiction Research, 3, 245-265.

Bad blood: A brief look at zoophagia

In previous blogs on vampirism as a sexual paraphilia and tampon fetishes, I briefly mentioned zoophagia. In his 2009 book Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices, Dr Anil Aggrawal defines zoophagia as eating live animals for erotic arousal. The online Wiktionary provides the same definition but also adds that it is another name for Renfield’s Syndrome (which I also covered in my blog on vampirism as a sexual paraphilia). Renfield’s Syndrome (as yet) does not appear in the Diagnostic and Statistical Manual of Mental Disorders but has been described as consisting of three stages (of which only one stage comprises zoophagia). More specifically:

• 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.

What is clear from the description of zoophagia as part of Renfield’s Syndrome is that sexual pleasure and sexual arousal do not appear to be part of the motivation to engage in the behaviour. Of all the sexual paraphlias I have ever written about, zoophagia is one of the few that I find it hard to imagine what the etiology of the behaviour involves. How does anybody end up developing sexual pleasure from eating animals while they are still alive?

There is very little written about zoophagia from an academic perspective. Most references to the behaviour are found in the forensic crime literature in relation to sexual homicides or as a behaviour associated with specific events such as satanic rituals (although this is more to do with haematophagy – the drinking of animal blood – than zoopahgia). As Dr. Eric Hickey notes in his 2010 book Serial Murderers and Their Victims, in most countries, drinking blood is not a crime. Zoophagia is arguably a sub-type of haematophilia (i.e., a sexual paraphilia in which individuals derive sexual pleasure and arousal from the tasting or drinking blood). Dr. Hickey also noted the relationship between zoophagia and haematophilia:

“[Haematophilia] is usually done in the presence of others. Most persons engaging in this form of paraphilia also have participated in or have co-occurring paraphilia often harmful to others. In addition, a ‘true hematolagniac’ is a fantasy-driven psychopath and to be considered very dangerous. According to Noll (1992), such desires are founded in severe childhood abuse. The child may engage in auto-vampirism in tasting his own blood and during puberty. These acts are eventually sexualized and reinforced through masturbation. A progressive paraphilic stage during adolescence is the sexual arousal of eating animals and drinking their blood (zoophagia) while masturbating. The compulsive, fantasy driven, sexual nature of this paraphilia creates a very dangerous adult”.

One of the most infamous serial killers that engaged in zoophagic activity was the German Peter Kurten (1883-1931), a mass murderer nicknamed the ‘Vampire of Dusseldorf’ (a case study also written about by Dr. Louis Schlesinger in his 2004 book Sexual Murder). Citing the work of criminologist Herschel Prins published in a 1985 issue of the British Journal of Psychiatry, Dr. Hickey recalled that:

“Kurten was raised in a very physically and sexually abusive home where he witnessed his alcoholic father raping his mother and sisters. He also engaged in sexually abusing his sisters…At age 11 he was taught by the local dog catcher how to torture dogs and sheep while masturbating. He developed multiple paraphilia including vampirism, hematolagnia, necrophilia, erotophonophilia, and zoophagia and was known to drink directly from the severed jugular of his victims. He raped, tortured, and killed at least nine known victims although he was believed to have murdered several others. He used hammers, knives, and scissors to kill both young girls and women and admitted that he was sexually aroused by the blood and violence. Some victims incurred many more stab wounds than others, and when asked about this variation he explained that with some victims his orgasm was achieved more quickly…Before his beheading he asked if he would be able to hear the blood gushing from his neck stump because “that would be the pleasure to end all pleasures”.

Most of the literature on the drinking of blood for sexual pleasure concerns humans and is found in the studies on clinical vampirism (that I reviewed in a previous blog). From the few case studies I have read where zoophagia was mentioned in passing, all of the people written about engage in other sexually paraphilic behaviours (similar to that of Kurten outlined above). There may also be links between zoophagia and sexual cannibalism (which I also covered in a previous blog). For instance, some zoophagic activity might be viewed as omophagic activity in which the act is a form of symbolic ritual where the person consuming the blood and/or flesh of a live animal believes they are incorporating the ‘life force’ of the animal in question. For instance, an entry in Murderpedia claims:

“Some killers have adopted a form of omophagia, which is called zoophagia, as a means of possessing their victims. Zoophagia is the consumption of life forms, as seen in the character of Renfield in Dracula, who progresses from spiders to flies to birds to cats. The idea is to ingest increasingly sophisticated life forms as a way to improve one’s own”

An online article on vampires and the fetish scene by the Occult and Violent Ritual Crime Research Center notes that some of the behaviours that vampires engage in are similar to behaviours engaged in by fetishists. In a section on ‘blood rituals and blood play’, the article notes that throughout history and across cultures, people have attributed sacred and magical qualities to blood, and that blood rituals include drinking and/or pouring blood on the body. It also noted that:

“In some cultures it was believed that drinking the blood of a victim would endow you with the victim’s strength. Similarly by drinking the blood of an animal you would acquire its qualities…The use of blood is commonly referred to as blood sports, blood play, blood lust and blood fetishism”.

Any information that we currently have on zoophagia comes from clinical and/or forensic case studies. It would appear that zoophagia is incredibly rare, usually occurs among males, often coincides with other sexually paraphilic behaviour, and is most likely to occur among those with psychopathic and/or serial killing tendencies (unless the behaviour is part of a satanic and/or other ritualistic event).

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.

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.

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

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

Occult and Violent Ritual Crime Research Center (2012). Renfield’s Syndrome. Located at: http://www.athenaresearchgroup.org/renfieldsyndrome.htm

Perlmutter, D. (2004). Investigating Religious Terrorism and Ritualistic Crimes.  Boca Raton, Florida: CRC Press LLC.

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

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

The need in deed: Is ‘loss of control’ always a consequence of addiction?

I recently published a potentially controversial paper in the journal Frontiers in Psychiatry arguing that loss of control may not always be a natural consequence of addiction. Research into addiction has a long history although there has always been much debate as to what the key components of addiction are. Irrespective of the theory and model of addiction, most theorizing on addiction tends to assume (implicitly or explicitly) that ‘loss of control’ is central (if not fundamental) to addiction. My paper challenges such notions by arguing that there are a minority of individuals who appear to be addicted to a behaviour (i.e., work) but do not necessarily appear to display any loss of control.

Research into many different types of addiction has shown that addicts are not a homogeneous group, and this may also have implications surrounding control and loss of control. Many years ago, in my 1995 book Adolescent Gambling, I argued that in relation to problem gambling there appear to be at least two sub-types of addiction – primary addictions and secondary addictions. I defined primary addictions as those in which a person is addicted to the activity itself, and that individuals love engaging in the activity whether it is gambling, sex or playing video games. Here, the behaviour is primarily engaged in to get aroused, excited, and/or to get a ‘buzz’ or ‘high’. I defined secondary addictions as those in which the person engages in the behaviour as a way of dealing with other underlying problems (i.e., the addiction is symptomatic of other underlying problems). Here the behaviour is primarily engaged in to escape, to numb, to de-stress, and/or to relax.

Therapeutically, I argued that it is easier to treat secondary addictions. My argument was that if the underlying problem is addressed (e.g., depression), the addictive behaviour should diminish and/or disappear. Primary addicts appear to be more resistant to treatment because they genuinely love the behaviour (even though it may be causing major problems in their life). Furthermore, the very existence of primary addictions challenges the idea that loss of control is fundamental to definitions and concepts of addiction. Clearly, people with primary addictions have almost no desire to stop or cut down their behaviour of choice because it is something they believe is life affirming and central to the identity of who they are. But does lack of a desire to stop the behaviour they love prevent ‘loss of control’ from occurring? Arguably it does, particularly when examining the research on workaholism.

I have popularized the ‘addiction components model’, particularly in relation to behavioural addiction (i.e., non-chemical addictions that do not involve the ingestion of a psychoactive substance). The addiction components model operationally defines addictive activity as any behaviour that features what I believe are the six core components of addiction (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict and relapse, and which I outlined in my very first blog on this site)

One of the observations that can be made by examining these six criteria is that ‘loss of control’ is not one of the necessary components for an individual to be defined as addicted to an activity. Although I acknowledge that ‘loss of control’ can occur in many (if not most) addicts, loss of control is subsumed within the ‘conflict’ component rather than a core component in and of itself. The main reason for this is because I believe that there are some addictions – particularly behavioural addictions such as workaholism – where the person may be addicted without necessarily losing control. However, such a claim depends on how ‘loss of control’ is defined and the highlights the ambiguity in our standard understanding of addiction (i.e., the ambiguity of control as ability/means versus control as goal/end).

When theorists define and conceptualise ‘loss of control’ as applied to addictive behaviour, it typically refers to (i) the loss of the ability to regulate and control the behaviour, (ii) the loss of ability to choose between a range of behavioural options, and/or (iii) the lack of resistance to prevent engagement in the behaviour. In some behaviours such as workaholism and anorexia, the person arguably tries to achieve control in some way (i.e., over their work in the case of a workaholic, or over food in the case of an anorexic). However, this in itself is not a counter-example to the idea that addiction is a ‘loss of control’ if workaholics and anorexics have lost the ability to control other aspects of their day-to-day lives in their pursuit of control over work or food (i.e., there is a difference between control as the goal/end of behaviour, and control as an ability/means.

There is an abundance of research indicating that one of the key indicators of workaholism (alongside such behaviours as high performance standards, long working hours, working outside of work hours, and personal identification with the job) is that of control of work activities. In a recent paper I wrote with my colleague Dr. Maria Karanika-Murray in the Journal of Behavioral Addictions, we also noted that the need for control is high among workaholics, and as a consequence they have difficulty in disengaging from work leading to many other negative detrimental effects on their life such as relationship breakdowns. Even some of the instruments developed to assess workaholism utilize questions concerning the need to be in control.

There are also other studies that suggest some workaholics do not experience a ‘loss of control’ in the traditional sense that is used elsewhere in the addiction literature. For instance, in a 2004 issue of the Journal of Organizational Change Management, Dr. Peter Mudrack reported that two particular aspects of obsessive-compulsive personality (i.e., being stubborn and highly responsible) were predictive of workaholism. A very recent paper by Dr. Ayesha Tabassum and Dr. Tasnuva Rahman in the International Journal of Research Studies in Psychology noted that perfectionist workaholics experience an overbearing need for control and are very scrupulous and detail-oriented about their work. Unusually among addictions, workaholics usually have no desire to reduce or regulate their work behaviour (i.e., there is no ambivalence or conflicting desire for them). In this instance, there is no evidence of ‘loss of control’ as traditionally understood, because if they had ambivalent or conflicting desires, they would change their behaviour (i.e., reduce the amount of time they spend working). Although not an exhaustive list of studies, those mentioned here appear to indicate that some workaholics appear to be more in control than not in control.

When the addiction is primary, the goal/end of the behaviour is desired and/or endorsed without ambivalence by the addict. In these situations (as in some cases of workaholism), there is no evidence for loss of control, because no (failed) attempts are made by the addict to alter their behaviour. However, this could arguably still be compatible with the claim that there is loss of control in the sense of ability and/or means, because, if the workaholic tried to work less (or work in a less controlling way) because they started to recognize ill effects the addictive behaviour was having on their personal life, then they may fail to do so. Therefore, the lack of evidence is indicative rather than conclusive.

However, one of the reasons that workaholism raises interesting theoretical and conceptual issues concerning the loss of control is that it is an example of an addiction where the goal/end is itself a form of control (i.e., control over their productivity/outputs, control over others, control over time-keeping, etc.). Unlike many other addictions, such behaviour is not impulsive and/or chaotic but carefully planned and executed. So this raises the question, in what sense is workaholism a loss of control, understood in the typical way, as ability/means to the behaviour’s goal/end? In some cases of workaholism, there is no evidence that the workaholic lacks control over this goal/end, as they do not try to change their behaviour (and thus cannot fail to do so).

It could be argued – and this is admittedly speculative – that ‘loss of control’ as is traditionally understood appears to have a greater association with secondary addiction (i.e., where an individual’s addiction is symptomatic of other underlying problems) than primary (or ‘happy’ or ‘positive’) addiction (i.e., where an individual feels totally rewarded by the activity despite the negative consequences). Such a speculation has good face validity but needs empirical testing. However, a complicating factor is the fact that my studies on adolescent gambling addicts have demonstrated that some individuals start out as primary addicts but became secondary addicts over time. Again, this suggests that control (and loss of it) may be something that changes its nature over time.

In essence, workaholics appear to make poor choices and/or decisions that have wide-reaching detrimental consequences in their lives. However, at present we lack evidence that (should they decide otherwise) they would be unable to work in a more healthy way. Furthermore, and equally as important, the nature of workaholic behaviour is not impulsive and chaotic, but carefully planned and executed. This is particularly striking among some workaholics, because as I have noted, it is an addiction that for some individuals they continue to work happily despite objectively negative consequences (e.g., relationship breakdowns, neglect of parental duties, etc.). What the empirical research on workaholism suggests is that it is an example of an addiction in which the problem is better characterized as loss of prudence rather than loss of control, as traditionally understood.

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

Further reading

Andreassen, C.S., Griffiths, M.D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.

Andreassen, C. S., Torsheim, T., Brunborg, G. S., & Pallesen, S. (2012) Development of a Facebook addiction scale. Psychological Reports, 110, 501-517.

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

Griffiths, M.D.  (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M.D. (2011). Workaholism: A 21^st century addiction. The Psychologist: Bulletin of the British Psychological Society, 24, 740-744.

Griffiths, M.D. & Karanika-Murray, M. (2012). Contextualising over-engagement in work: Towards a more global understanding of workaholism as an addiction. Journal of Behavioral Addictions, 1(3), 87-95.

Mudrack, P.E. (2004). Job involvement, obsessive-compulsive personality traits, and workaholic behavioral tendencies. Journal of Organizational Change Management, 17, 490-508.

Mudrack, P.E. & Naughton, T.J. (2001) The assessment of workaholism as behavioral tendencies: Scale development and preliminary empirical testing. International Journal of Stress Management, 8, 93-111.

Tabassum, A. & Rahman, T. (2012). Gaining the insight of workaholism, its nature and its outcome: A literature review. International Journal of Research Studies in Psychology, 2, 81-92.

Better collate than never: Can collecting be an addiction?

In a previous blog on bibliomania (i.e., an obsessive-compulsive disorder associated with the collecting and hoarding of books), I briefly mentioned that collecting more generally could perhaps be addictive for some people. Writing in a 2006 issue of the International Journal of Psychoanalysis, Dr. Peter Subkowski wrote that the urge to collect is a ubiquitous phenomenon that has anthropological, sociobiological, and individual psychodynamic roots. Dr. Russell Belk writing in a 1991 issue of the Journal of Social Behavior and Personality described collectors of mass-produced objects as falling into one of two main types: the taxonomic collector who attempts to own an example of every type of a series of items produced, and the aesthetic collector who simply gathers items because they are pleasing in some way.

So what are the motivations for collecting? In a 1991 issue of the Journal of Social Behavior and Personality, Dr. Ruth Formanek suggested five common motivations for collecting. These were: (i) extension of the self (e.g., acquiring knowledge, or in controlling one’s collection); (ii) social (finding, relating to, and sharing with, like-minded others); (iii) preserving history and creating a sense of continuity; (iv) financial investment; and (v), an addiction or compulsion. Formanek claimed that the commonality to all motivations to collect was a passion for the particular things collected. One of the prime researchers in the ‘collecting’ field is Dr. Russell Belk who has written many papers and chapters on the topic. In a 1991 book chapter, Dr. Belk (along with Melanie Wallendorf, John F. Sherry, Jr., and Morris B. Holbrook) noted that:

“In examining literary and social science treatments of collecting…some regard it as a passion, others as a disease. It is frequently described as a pleasurable activity that can have some unpleasant consequences. In its pleasurable aspect, collecting embodies the characteristics of flow…It is an optimal experience that is psychologically integrating and socially beneficial. In its darker aspect, collecting is an activity over which many consumers fear losing control. Whether likened to idolatry or illness, collectors acknowledge the very real possibility that collecting can become addictive. Danet and Katriel (1990) suggest that the seemingly self-deprecating admission of addiction to one’s collection can be a way of disclaiming responsibility for uninhibited collecting. At the same time they recognize that ‘serious’ collectors relish their ability to freely express passion in their collecting activity. What apparently is being negotiated in the area between passion and addiction is the definition of whether the collector controls or is controlled by the activity of collecting”.

The chapter also claimed that the tendency to pursue an altered state of consciousness produced by any ritual activity “whether behaviorally via collecting, or pharmacologically via chemical use” is cross-culturally universal. Obviously they acknowledged that most collectors are not addicts but claimed there was “compelling evidence of its pervasiveness in the observations of others” based in self-report surveys, and the labels by which collectors in their research studies described themselves (e.g., “magazineaholic”, “getting a Mickey Mouse fix”, “print Junkie”). Brenda Danet and Tamara Katriel claimed some of their collectors’ said it was “a disease”. They also reported that Sigmund Freud amassed a large collection of 2,300 Roman, Greek, Egyptian, Assyrian, and Chinese antiquities that eventually numbered approximately 2300 and described his collecting passion as “an addiction second in intensity only to his nicotine addiction“. Based on their interviews with collectors, the chapter then went on to claim:

“Although almost any behavior can become addictive, the pattern of behavior characteristic of collectors makes it especially prone to addiction. Most collectors interviewed mentioned the search for additions to a collection as the central activity of their collecting behavior. Rather than spend time examining or organizing items that are already in the collection, collectors prefer to search or shop for additions to the collection. Search behavior may be compulsively and ritualistically enacted. Acquiring rather than possessing provides the temporary fix for the addict. A sense of longing and desire — a feeling that something is missing in life — is temporarily met by adding to the collection. But this is a temporary fix, a staving off of withdrawal, followed by a feeling of emptiness and anxiety that is addressed by searching for more. Shopping and searching are the ritualized means by which the collector obtains a sense of competence and mastery in life. These activities are the bittersweet consequences of experiencing longing in the arena of the marketplace”.

They also noted that searching and shopping for collection items highlight the ritualized aspects (i.e., it is patterned and repetitive). They provided the example of a Barbie doll collector that spent considerable time at doll shows that had specific rules that guided his doll buying (e.g., having the dealer completely undress then redress the doll to allow him to see if any part of the body is damaged). They also reported that items for their collection found in the search were often seen as having irresistible power over the person. One collector of antique bronzes was quoted as saying “I just had to have it. It had to be mine”. Searching for such items are “not the only addictive focus for collectors”. Belk and colleagues reported that:

“Compulsive attention to and control over the objects in the collection provides an additional source of feelings of control and mastery –important feelings to an addict. For example, one interpretation of the propensity of collectors to will their collections to museums is that, by doing so, they retain a certain sense of control of the collection by insuring that it will not fall into the hands of another collector. Collecting activity allows a collector to avoid other aspects of life. It is a form of withdrawal from other aspects of life that is nevertheless often positively sanctioned…On the whole, collecting, particularly for the addict, involves the individual in a repetitive, predictable pattern of behavior which can provide a form of solace for someone who is troubled by living in an unpredictable world”.

In a 1995 paper in the Journal of Economic Psychology, Dr. Belk carried out in-depth interviews with 200 collectors. He claimed that for most, collecting was a highly beneficial activity. However, he also noted there were extreme cases where collecting was found to be addictive and dysfunctional for the affected individuals and their families. He also wrote that:

“Collectors often refer to themselves, only half in jest, as suffering from a mania, a madness, an addiction, a compulsion, or an obsession. Because collecting is generally a socially approved activity, no one is likely to treat such a confession as stigmatizing in the way that it would be for an alcoholic, a heroin addict, a compulsive gambler, or someone truly believed to be mentally ill…But like much humor there is an uneasy fear behind these self-admissions, for some collectors really are out of control”.

The most vivid example that Belk encountered was a dealer and collector of Disney cartoon character replicas who was a recovering poly-drug abuser who himself described his collecting behaviour as an addiction. Over many years, he accumulated a large collection of Mickey Mouse memorabilia to obtained his “Mickey fix”. Consequently he was often unable to pay his house rent or pay his bills. Belk claimed that he thrill of collecting and displaying his objects eventually threatened his psychological wellbeing and in the collector’s words had to go “cold turkey” and cease collecting.

Finally, in an online article about addictive collecting, Hale Dwoskin, CEO and director of training of Sedona Training Associates provided a list of symptoms of a collecting addiction:

• You look for/buy/trade collectibles for hours on end, and the time you spend doing this is increasing
• You think about collectibles constantly, even when you’re not collecting
• You have missed important meetings/events because of collecting
• It’s difficult for you to not buy more collectibles, even for just a few days
• You try to sneak more collectibles into your home
• You have tried, unsuccessfully, to stop collecting
• Your family or friends have asked you to cut back on collecting
• Your personal interests have changed because of your collecting
• You have lost a personal or professional relationship because of collecting

As an ‘avid’ collector myself (of records, CDs and music in general) I can certainly see how collecting can become an expensive habit that goes beyond disposable income. Although I think that it is theoretically possible to be addicted to collecting, the number of genuine ‘collecting addicts’ is likely to be very low.

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

Further reading

Belk, R. W. (1982). Acquiring, possessing, and collecting: fundamental processes in consumer behavior. Marketing Theory: Philosophy of Science Perspectives, 185-190.

Belk, R. W. (1992). Attachment to possessions. In: Place attachment (pp. 37-62). New York: Springer.

Belk, R. W. (1994). Collectors and collecting. Interpreting objects and collections, 317-326.

Belk, R. W. (1995). Collecting as luxury consumption: Effects on individuals and households. Journal of Economic Psychology, 16(3), 477-490.

Belk, R.W., Wallendorf, M., Sherry, J.F., & Holbrook, M.B. (1991). Collecting in a consumer culture. In: Highways and buyways: Naturalistic research from the consumer behavior odyssey, pp.178-215.

Danet, B. & Katriel, T. (1989). No two alike: The aesthetics of collecting. Play and Culture, 2, 253-277.

Formanek, R. (1991). Why they collect: Collectors reveal their motivations. Journal of Social Behavior and Personality, 6(6), 275-286.

MacLeod, K. (2007). Romps with Ransom’s King: Fans, Collectors, Academics, and the MP Shiel Archives. ESC: English Studies in Canada, 30(1), 117-136

Subkowski, P. (2006). On the psychodynamics of collecting. International Journal of Psychoanalysis, 87, 383-401.

Cock tales: A brief look at Penile Dysmorphic Disorder

In a previous blog, I examined Body Dysmorphic Disorder (BDD). At its simplest level, BDD is a distressing, handicapping, and/or impairing preoccupation with an imagined or slight defect in body appearance that the sufferer perceives to be ugly, unattractive, and/or deformed. BDD sufferers can think about their perceived defect for hours and hours every day. The International Classification of Diseases (ICD-10) criteria for BDD is:

• Persistent belief in the presence of at least one serious physical illness underlying the presenting symptom(s), even though repeated investigations and examinations have identified no adequate physical explanation, or a persistent preoccupation with a presumed deformity or disfigurement.
• Persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or abnormality underlying the symptoms.

One particular body part that has been the focus of some research in the BDD field is that of genitalia. Many men worry about the size of their penis and think it is too small. This is perfectly normal and the worry or concern is highly unlikely to be a symptom of BDD. In a 2004 issue of the Postgraduate Medical Journal, British psychiatrist Dr David Veale reported that although there are broad similarities between the genders in BDD, there are some differences. For instance, men with BDD show a greater preoccupation with their genitals, and women with BDD are more likely to have a co-morbid eating disorder. Dr. David Sarwer (writing in a 2006 issue of Plastic and Reconstructive Surgery) asserted that the rate of body dysmorphic disorder should be examined among patients re-questing atypical procedures and cites the example of those individuals requesting genital surgery.

Back in 2008, Channel 4 in the UK had a television series called Penis Envy. The first episode (The Perfect Penis) featured a US psychology student who paid $4000 to have his penis lengthened by cutting the ligament in his pubis. Such actions might be indicative of BDD but the programme didn’t explore this facet. Following such operations, men then have to spend the following weeks suspending a weight from their penis for at least eight hours a day. For all the financial and physical burdens faced, the average increase in length is only 0.5-3cm (with official statistics being closer to 0.5cm than 3cm). Other methods of increasing genital size include the injection of silicon into the penis (although this is dangerous and can result in a silicon embolism).

Dr. Stephen Snyder (Associate Clinical Professor of Psychiatry, Mount Sinai School of Medicine, New York, US) was interviewed about (so-called) ‘Penile Dysmorphic Disorder’ (PDD) in an online Psychology Today article. He was quoted as saying:

“I don’t know of any statistics on [PDD]. Anxiety or insecurity about penis size is extremely common in men. It would be difficult to determine how frequently the more serious condition of penis-focused BDD occurs. People with BDD tend to avoid mental health specialists…It’s much more likely I think that a man with penile BDD will purchase penis enlargement equipment or consult a surgeon than consult someone like me…Some people seem to have an innate tendency for obsessive thinking. Why some of these people develop BDD, and others OCD or Anorexia Nervosa is unknown…A man who begins to obsess about the size of his penis may begin to compulsively and repeatedly measure his erections, and to avoid dating because he’s convinced he’ll be humiliated. Then the whole thing can spiral out of control, until ultimately he’s online studying penis enlargement techniques”.

A 2006 study led by Dr. J. Lever and published by Psychology of Men and Masculinity reported that in an online survey of over 52,000 participants, most male participants rated their penis as average (66%) and only 22% as large and 12% as small. Among the female participants, around 85% of women were satisfied with their partners’ penile size, while only 55% of men were satisfied, with 45% wanting to be larger (and 0.2% to be smaller).

Just recently, Dr. Warren Holman highlighted the case of ‘Sam’, a 17-year-old white male from a middle-class Jewish family living in Midwest USA with penile dysmorphic disorder (in a 2012 issue of Social Work in Mental Health). As Dr. Holman reported:

“Sam had stopped attending school several weeks earlier, and on many days would not even leave his home. He said he wanted to remain at home and away from school because, ‘My penis is shrinking and people can tell.’ Sam reported he had had his anxiety about his penis for about a year, but until recently had been able to reason himself out of it…Sam was well related, and his mental status was unremarkable except for his belief about his penis”.

Dr. Holman believed that Sam’s conviction that his penis was shrinking (and people could tell) suggested three possible diagnoses (i.e., social phobia; BDD and/or delusional disorder of the somatic type; or schizophrenia). Holman eventually reached the conclusion that Sam’s beliefs were due to BDD although did say that it “may be in a prodromal phase of schizophrenia”. Sam was treated via a form of psychodynamic counselling (which much to the disappointment of Holman ultimately failed perhaps because of initial misdiagnosis).

In 2007, British urologists Dr. Kevan Wylie and Dr. Ian Eardley published a review on penile size in BJU International. They summarized all of the studies on penile size that have examined flaccid penis length, stretched penis length, erect penis length, flaccid penis girth and erect penis girth. They reported that:

“Stretched penile length in these studies was typically 12–13 cm, with an erect length of 14–16 cm. For girth, there was again remarkable consistency of results, with a mean girth of 9–10 cm for the flaccid penis and 12–13 cm for the erect penis…Concern over the size of the penis, when such concern becomes excessive, might present as the ‘small penis syndrome’ [SPS], an obsessive rumination with compulsive checking rituals, body dysmorphic disorder, or as part of a psychosis”.

However, they did also assert that more research was required on the effects of race and age on penile length. Wylie and Eardley speculate that SPS (or ‘locker room syndrome’ as they also call it) originates in childhood following the sight of their father’s, elder sibling’s and/or older friend’s penis. This appears to have support from a 2005 study (also published in BJU International). Dr. N. Mondaini and Dr. P. Gontero surveyed men who thought they had a small penis at an andrology clinic and reported that nearly two-thirds said their SPS had begun in childhood (63%) with the rest saying it began in adolescence (37%).

Wylie and Eardley also examined the treatment options of men with SPS and also examined the evidence of commercial penis extending techniques. They concluded that:

“It is recommended that the initial approach to a man who has SPS is a thorough urological, psychosexual, psychological and psychiatric assessment that might involve more than one clinician…Conservative approaches to therapy, based on education and self-awareness, as well as short-term structured psychotherapy [cognitive-behavioural therapy] are often successful, and should be the initial interventions in all men. Of the physical treatments available, there is poorly documented evidence to support the use of penile extenders. More information is need on the outcomes with these devices. Similarly, there is emerging evidence about the place of surgery and there are now several reports suggesting that dividing the suspensory ligament can increase flaccid penile length”.

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

Further reading

Goodman, M.P. (2009). Female Cosmetic Genital Surgery. Obstetrics and Gynecology, 113, 154-159.

Holman, W.D. (2012). “My Penis Is Shrinking and People Can Tell”: A Confusing Case of Apparent Body Dysmorphic Disorder. Social Work in Mental Health, 9, 319-335.

Morrison, T.G., Bearden, A., Ellis, S.R. & Harriman, R. (2005). Correlates of genital perceptions among Canadian post- secondary students. Electronic Journal of Human Sexuality, 8. Located at: http://www.ejhs.org/volume8/GenitalPerceptions.htm

Lever, J., Fredereicjk, D.A. & Peplau, L.A. (2006). Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men and Masculinity, 3,129-143.

Mondaini, N. & Gontero, P. (2005). Idiopathic short penis: myth or reality? BJU International, 95, 8–9.

Sarwer, D.B. (2006). Body Dysmorphic Disorder and cosmetic surgery. Plastic and Reconstructive Surgery, December, 168e-180e.

Snyder, S. (2011). When size obsession gets out of hand. Psychology Today, June 11. Located at: http://www.psychologytoday.com/blog/sexualitytoday/201106/when-size-obsession-gets-out-hand

Sondheimer, A. (1988). Clomipramine treatment of delusional disorder-somatic type. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 188-192.

Veale, D. (2004). Body dysmorphic disorder. Postgraduate Medical Journal, 80, 67-71.

Wylie, K.R. & Eardley, I. (2007). Penile size and the ‘small penis syndrome’. BJU International, 99, 1449–1455.

A word to the wise: A brief look at obsessive cruciverbalism

“Sixty-four million people do it at least once a week. Nabokov wrote about it. Bill Clinton even did it in the White House” (Marc Romano, 2005).

I’m sure many of you reading this opening quote will think that it refers to sexual infidelity but it doesn’t. I was also deliberately obtuse in the title of today’s blog to throw you off the scent of what today’s blog is about. Well, to put some of you out of your misery, the topic under the microscope today is crossword puzzles. For those who don’t know, a cruciverbalist is an enthusiast of word games (especially of crosswords). According to Michael Quinion in his excellent World Wide Words website:

“[The word ‘cruciverbalist’] seems to have appeared in English about 1980 (the first reference I can find is to the Compleat Cruciverbalist of 1981 by Stan Kurzban and Mel Rosen, subtitled ‘how to solve, compose and sell crossword puzzles for fun and profit’). However, Stan Kurzban tells me that Mel Rosen had encountered the word some years earlier in the title of a directory of crossword puzzle notables that was not widely circulated. Whatever its origin, cruciverbalist has spread into the wider language as a result of their efforts to the extent that it now appears in some larger recent US dictionaries. The word is a modern mock-Latin invention, being a translation back into Latin of the English crossword (using Latin crucis, cross, as in words like cruciform, plus verbum, word, as in verbose or verbatim).There is also cruciverbalism, for the art of crossword compilation or crossword fandom generally, but that is much rarer”.

The opening quote comes from Marc Romano’s 2005 book The Crossword Obsession: The History and Lore of the World’s Most Popular Pastime who asserted that: “the crossword puzzle has arguably been our national obsession since its birth almost a century ago”. Seeing the word ‘obsessive’ was enough to make me think it was a topic worthy of consideration of writing a blog about it (especially when reading the accompanying blurb for Romano’s book):

“Saying this is a book about puzzles is to tell only half the story. It is also an explanation into what crosswords tell us about ourselves – about the world we live in, the cultures that nurture us, and the different ways we think and learn. If you’re a puzzler, Crossworld will enthrall you. If you have no idea why your spouse send so much time filling letters into little white squares, Crossworld will tell you – and with luck, save your marriage”.

On a personal note, I ought to declare a vested self-interest in that I been doing cryptic crosswords since I was taught to do them by my father in my mid-teens. In the early 1990s until the late 1990s I did (or rather attempted) The Guardian’s cryptic crossword almost every day (the birth of my daughter put a stop to daily crosswords and what little spare time I had outside of my job). On the way to a conference in Bristol in 1998, I had a race on the train with one of my departmental colleagues (Bob Rotheram) as to who could complete that day’s Guardian crossword first. I even got a letter in The Guardian (November 26, 2002) about a crossword puzzle set by my favourite crossword setter (John Galbraith Graham, better known under his crossword compiling pseudonym ‘Araucaria’). Many of the clues in the prize crossword I had just completed related to an anagram of the word ‘presbyterians’. The letter I had published said:

“I don’t know what is worse. The fact that some clues in the prize crossword related to Britney Spears and her hit singles, or the sad fact that I knew the answers to them all!”

The fact that ‘presbyterians’ is an anagram of singer ‘Britney Spears’ I found amazing (although my favourite anagram in one of Araucaria’s crosswords was ‘synthetic cream’ being an anagram of the football team ‘Manchester City’). I am also a huge fan of crossword homophones (words that are pronounced the same but are completely different in definition and meaning) and on which most forms of punning are based. This includes many of my blog titles such as my articles on body dysmorphic disorder (‘Flaw management’), biting fetishes (‘Bit sighs’), pandrogyny (‘A gender setting’), and gambling spending (‘Stake and chips’), as well as my blogs on the psychology of revulsion (‘Disgust discussed’), Exploding Head Syndrome (‘A noise that annoys’) and Jerusalem Syndrome (‘Wholly holy’). I love crosswords so much that I even have an all-time favourite clue (“Late opening” [seven letters]; Answer: AUTOPSY). Total genius!

Doing crosswords appears to be a very popular hobby. According to Dean Olsher in his 2009 book, From Square One: A Meditation, with Digressions, on Crosswords, about 50 million American people do crosswords. Olsher says that for some, crosswords are a pastime and for others it is a form of escapism (suggesting that crosswords may produce psychological feelings and motivations associated with addictive behaviours). Olsher noted that some people like the film director Alfred Hitchcock “didn’t get” crosswords. Hitchcock told film actor, director and screenwriter Francois Truffaut that:

“I don’t really approve of whodunits because they’re rather like a jigsaw or crossword puzzle. No emotion. You simply wait to found out who committed the murder”

Olsher claims Hitchcock fell prey to a common false dichotomy that thinking and feeling are an either/or proposition. Olsher claims they are inextricable, and that cerebral and emotional satisfaction are not at odds with each other. For Olsher, crosswords can be an exhilarating experience and akin to seated meditation. However, he also notes that doing crosswords (based on his own personal experience) could be an addiction:

“It is more honest, though, to think of crosswords as a habit, like smoking. It’s just something to do, every day, because it’s there. When finished with a puzzle, I don’t pump my fists in triumph or congratulate myself for my perseverance. I solve crosswords because they bring on a feeling of emptiness, and paradoxically, that feeling seems to fill a hole deep inside. It’s not a release, it’s not a flushing out, although both those terms grasp at some aspect of it. Norman Mailer said that for him, solving the crossword every day was like combing his brain. This simile is strong because it has nothing to do with usual mental fitness. It’s not about intelligence or holding onto memory. Crosswords bring about a focused state of mind, the elusive ‘flow state’. Then there are days when I decide that this is all an elaborate self-deception. That the puzzle is indeed an escape mechanism. The crossword addiction is not a metaphor but a destructive literal truth”

I was surprised to find there has been quite a lot of academic research on the benefits of doing crosswords (although very little on whether doing crosswords can be obsessive and/or addictive). However, the psychologist Dr. Howard Rachlin does mention in a number of his writings on addiction that there are many activities that could be described as ‘positive addictions’ including “listening to classical music, collecting stamps, exercise, reading novels, doing crossword puzzles”. Dr. Rachlin also noted in a paper published in a 2002 issue of the journal Behavioral and Brain Sciences (BBS):

“Patterns of behavior may be maintained without extrinsic rewards. For example, on a relatively small scale, activities such as solving jigsaw or crossword puzzles are valuable in themselves. People, like me, who like to do crossword puzzles, find value in the whole act of doing the puzzle. When I sit down on a Sunday morning to do the puzzle I am not beginning a laborious act that will be rewarded only when it is completed. Yet, despite the lack of extrinsic and intrinsic reward for putting in that last particular letter, completing the puzzle is, for me, a necessary part of its value. Like listening to symphonies, the pattern is valuable only as a whole. Extrinsic rewards may initially put together the elements of these patterns but the patterns, once formed, are maintained by their intrinsic value. The cost of breaking the pattern is the loss of this value – even that of the parts already performed”.

However, Rachlin is not without his critics. In responses to the BBS paper, Dr. Stephen Kaplan and Dr. Raymond De Young claimed that Rachlin’s interpretation of intrinsic motivation as arising from a string of habits was far from convincing. More specifically, they noted that the “fascination with crossword and jigsaw puzzles seems far more likely to be an expression of the human inclination to solve problems, a tendency humans share with nonhuman primates”. Another response to the BBS paper by Dr. Thomas R. Zentall claimed that the concept of intrinsic reinforcement is needed to explain the variety of behaviour that has no extrinsic material or social reward, such as crossword puzzle solving. He argues that:

“Intrinsic reinforcers are difficult to assess. They are what [are] left once you have ruled out extrinsic reinforcers, and in the case of humans, typically we assess them by means of verbal behavior (e.g., ‘I just like doing it’). But this sort of definition can easily become circular, especially when we are talking about behavioral patterns that are themselves not clearly defined. One can hypothesize that extrinsic reinforcers become internalized, but that does not explain, it only describes”.

Doing crosswords may even be of psychological and practical benefit. For instance, Dr. Mike Murphy and Dr. Roisin Cunningham published a paper last year in the Irish Journal of Psychology claiming that: “a crossword a day improves verbal fluency”. More specifically they examined ‘semantic verbal fluency’ (SVF) an important contributor to general communication ability. In their study, 34 final year students completed a daily crossword for one month and compared this to a control group of 40 students who did not do any crosswords. Their results indicated that the crossword group experienced greater improvement in SVF than the control group. They concluded that doing simple crosswords may be a relatively straightforward way improving SVF among students who are about to enter the job market and need good transferable skills.

Dr. Graham Pluck and Dr. Helen Johnson writing in a 2011 issue of Education Science and Psychology claim that stimulating curiosity (with activities such as crosswords) can enhance learning. They drew on the work of Dr. Ludwig Lowenstein who noted that many features of human behaviour appear counter-productive on the surface but are not. For instance:

“Lowenstein discusses the interest that many people have in completing puzzles such as crosswords, or why soap operas end on cliff-hangers. According to the theory, the information gaps that people are exposed to act to motivate them to obtain the missing information, either by persevering to complete the puzzle or tuning in to watch the next episode of the soap opera”.

Another study led by Dr. Joshua Jackson and published in a 2012 issue of the journal Psychology and Aging claimed doing crosswords could change some aspects of personality among old-aged people. More specifically, they examined whether an intervention aimed to increase cognitive ability in older adults (i.e., doing crossword and Sudoku puzzles) affected the personality trait of openness to experience (i.e., being imaginative and intellectually oriented). In their study, old-aged adults completed a 4-month program in inductive reasoning training that included weekly crossword and Sudoku puzzles. They were then assessed continually over the following 30 weeks. Their findings showed that those who did crossword and Sudoku puzzles increased their openness scores compared to the control group. The authors claimed that this study is one of the very first to demonstrate that personality traits can change through non-psychopharmocological interventions.

Although there are a number of people online who have confessed as to being ‘crossword addicts’, (including the US rock singer and record producer Todd Rundgren in a June 2013 interview with Uncut magazine), I have yet to find any empirical evidence that it is negatively detrimental in people’s lives. For most, even those who describe themselves as ‘crossword obsessives’, it is a behaviour that adds to and enhances their lives.

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

Further reading

Amende, C. (2001). The Crossword Obsession: The History and Lore of the World’s Most Popular Pastime. New York: Berkeley.

Davis, T.M., Shepherd, B. & Zwiefelhofer, T. (2009). Reviewing for exams: Do crossword puzzles help in the success of student learning? Journal of Effective Teaching, 9, 4-10.

Jackson, J.J., Hill, P.L., Payne, B.R., Roberts, B.W., & Stine-Morrow, E.A. L. (2012). Can an old dog learn (and want to experience) new tricks? Cognitive training increases openness to experience in older adults. Psychology and Aging, 27, 286-292.

Kaplan, S. & De Young, R. (2002). Toward a better understanding of prosocial behavior: The role of evolution and directed attention Behavioral and Brain Sciences, 25, 263-264.

Murphy, M. & Cunningham, R.K. (2102). A crossword a day improves verbal fluency: A report of an intervention study. Irish Journal of Psychology, 133, 193-198.

Olsher, D. (2009). From Square One: A Meditation, with Digressions, on Crosswords. New York: Simon & Schuster.

Pluck, G. & Johnson, H. (2011). Stimulating curiosity to enhance learning. Education Science and Psychology, 2(19), 24-31.

Rachlin, H. (2002). Altruism and selfishness. Behavioral and Brain Sciences, 25, 239-250.

Rachlin, H. (2003). Economic concepts in the behavioural study of addiction. In R.E. Vuchinich & N. Heather (Eds.), Choice, Behavioural Economics and Addiction. (pp.129-149). Oxford, UK: Pergamon Press.

Romano, M. (2005). Crossworld: One Man’s Journey into America’s Crossword Obsession. Blackpool: Broadway.

Underwood, G., Deihim, C. & Batt, V. (1994). Expert performance in solving word puzzles: From retrieval cues to crossword clues. Applied Cognitive Psychology, 8, 531-548.

Zentall, T.R. (2002). A potentially testable mechanism to account for altruistic behavior Behavioral and Brain Sciences, 25, 282.

What’s bugging you? A beginner’s guide to Ekbom’s syndrome

It was only a few months ago that I watched the 2006 film Bug for the very first time. Directed by William Friedkin, it tells the story of a mentally ill drifter called Peter Evans (with a great performance by Michael Shannon). Evans ends up having a sexual relationship with Agnes White, a bisexual alcoholic junkie (played surprisingly well by Ashley Judd). During the film, Peter confides in Agnes his belief that he has a colony of microscopic bugs infested one of his molar teeth (and then in one ‘memorable’ scene starts pulling his own teeth out). Evans’ paranoia becomes increasingly erratic and becomes a shared belief with White (who also comes to believe that they are both infested with microscopic bugs; this sharing of a delusional belief is known as a ‘folie à deux’ [French for ‘a madness shared by two people’, a shared psychosis] and would make a good blog topic). However, today’s blog focuses on imagined bug infestation (i.e., delusional parasitosis) that is known in psychological and psychiatric terms as Ekbom’s syndrome (named after the Swedish neurologist Karl Ekbom who first described the condition in a number of published papers in the late 1930s).

As you have probably gathered from my quick film synopsis above, Ekbom’s syndrome (ES) is a type of psychosis in which sufferers have a vehement delusional belief that they are infested with parasites that those affected describe as bugs or insects crawling around under their skin (when in reality they simply do not exist). I ought to add that the characters in Bug also appeared to be suffering from ‘delusory cleptoparasitosis’ (DC) another type of insect psychosis in which the sufferer thinks the place where they live is infested with parasites (rather than from within their body). As a consequence, both ES and DC sufferers are more likely to seek the help of skin specialists (e.g., dermatologists) and insect specialists (e.g., pest control, entomologists) than psychologists.

In essence, ES is a tactile hallucination and is also known as ‘formication’ (which is the word that describes the feeling of insects crawling and/or burrowing underneath the skin’s surface. Formication is also one form of parasthaesia (of which other examples include the ‘pins and needles’ tingling sensations that many people experience regularly). Parasthaesia includes any non-permanent skin sensation including tickling, pricking, tingling, numbness, and/or burning. ES sufferers will focus on any unusual body mark on their skin as ‘evidence’ that they have a parasitic infection. It is not uncommon for obsessive and/or compulsive checking of the body to occur. The prevalence of ES is unknown although Dr. J. Koo and Dr. C. Gambla reported in the journal Dermatologic Clinic that they see around 20 new cases per year in the large US referral clinic.

In some psychological circles, ES has been used synonymously with Wittmaack-Ekbom syndrome that is more associated with ‘restless leg syndrome’ (RLS; something that I myself have suffered from due to a chronic spinal condition that I have). When I get my bouts of RLS, it really does feel as though I have tiny insects moving about inside my right leg. The difference between ES and RLS is that RLS is a real physical condition that has bona fide physical basis whereas the basis for ES is an imaginary delusion. Clinical and medical research has shown that ES is associated with a number of comorbid conditions including affective psychosis, paranoid schizophrenia, organic brain disease, neurosis, and anankastic/paranoid personality disorder. It has also been reported in some people undergoing alcohol withdrawal, cocaine misuse, cerebrovascular disease, senile dementia, and thalamic brain lesions.

There can also be medical complications for ES sufferers. The fictional example of someone pulling their teeth out is not unknown although the gouging or digging out of the perceived parasites is more common. However, a paper by Dr. M. Nel and colleagues in the Journal of the South African Veterinary Association, most ES sufferers are able to function normally in all other aspects of their lives, in spite of their fixed parasitic delusions. They also noted that:

“The typical history often describes numerous attempts at eradicating the infestation. These could include taking medication, applying topical treatments, using pesticides, making use of exterminators, discarding clothing and possessions and even relocating…In a study of 94 patients (Ohtaki, 1991), most patients complained of itching and/or a tickling sensation. In order to rid themselves of the so-called parasites, patients often scratch, pick and wash frequently or use caustic agents on their skin, almost invariably leading to traumatic skin lesions”.

According to one meta-analytic study of 1,223 ES cases (published by Dr. W. Trabart in the journal Psychopathology), the occurrence of ES as a shared psychotic disorder is an uncommon phenomenon. He reported only about 5-15% of such cases were found. It was also reported that ES was more common amongst females (two-thirds female, one-third male), and is more prevalent in those over the age of 40 years. The symptoms had lasted three to four-and-a-half years. ES can be classified into three sub-types (primary; secondary-functional; and secondary-organic) based on the presenting symptoms:

• Primary ES refers to individuals that have the delusional parasitic infestation but no other comorbid conditions (i.e., other mental functioning is normal). Those where ES occurs by suggestion from another individual (e.g., the folie a deux case mentioned above) would be included in this ES sub-type. (It’s also worth noting that at least three studies have reported either the folie à deux or folie à trois among family members or loved ones including papers in the British Journal of Psychiatry and Dermatologica). Treatment is usually pharmacotherapy-based and utilizes drugs that are used in the treatment of other delusional-based syndromes (e.g., atypical antipsychotic drugs such as risperidone and olanzapine.
• Secondary-functional ES refers to individuals that have the delusional parasitic infestation and are associated with another psychiatric condition (e.g., clinical depression, schizophrenia).
• Secondary-organic ES refers to individuals that have the delusional parasitic infestation that is caused by another medical illness (e.g., cancer, diabetes, tubercolosis, hyperthyroidism, vitamin deficiency, cerebrovascular disease, neurological disorders). Other conditions can also facilitate ES including drug abuse (including stimulant psychosis), various allergies, and the menopause). Treating the primary disorder will often lead to a reduction or elimination of the ES symptoms.

The most recent review of the literature I came across was by Dr. Andrea Boggild and colleagues, and published in a 2010 issue of the International Journal of Infectious Diseases, they concluded that:

“In summary, [delusional parasitosis] is one of the more challenging entities that infectious diseases specialists will be enlisted to help treat. Unfortunately, optimal therapeutic regimens leading to sustained remission are lacking, and assurances on the part of the clinician do little to ameliorate patient suffering”.

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

Further reading

Berrios GE (1985). Delusional parasitosis and physical disease. Comprehensive Psychiatry 26, 395-403.

Boggild, A.K., Nicks, B.A., Yen, L., Voorhis, W.V., McMullen, R., Buckner, F.S., & Liles, W.C. (2010). Delusional parasitosis: six-year experience with 23 consecutive cases at an academic medical center. International Journal of Infectious Diseases, 14, e317–e321.

Bourgeois, M.L., Duhamel, P. & Verdoux, H. (1992). Delusional parasitosis: Folie à deux and attempted murder of a family doctor. British Journal of Psychiatry, 161, 709-711.

Frances, A. & Munro, A. (1989). Treating a woman who believes she has bugs under her skin. Hospital and Community Psychiatry, 40, 1113–1114.

Freinhar, Jack P (1984). Delusions of parasitosis. Psychosomatics, 25, 47-53.

Gieler, U. & Knoll, M. (1990). Delusional parasitosis as ‘folie à trois’. Dermatologica, 181, 122-125.

Goddard J (1995). Analysis of 11 cases of delusions of parasitosis reported to the Mississippi Department of Health. Southern Medical Journal 88, 837-839.

Gould, W.M. & Gragg, T.M. (1976). Delusions of parasitosis. Archives of Dermatology 112, 1745–1748.

Grace, K.J. (1987). Delusory cleptoparasitosis: Delusions of arthropod infestation in the home. Pan-Pacific Entomologist, 63, 1-4.

Koblenzer, C.S. (1993). The clinical presentation, diagnosis and treatment of delusions of parasitosi: A dermatologic perspective. Bulletin of the Society of Vector Ecologists 18, 6-10.

Koo, J. & Gambla, C (1996). Delusions of parasitosis and other forms of monosymptomatic hypochondriacal psychosis. General discussion and case illustrations. Dermatologic Clinic, 14, 429-438.

Morris, M. (1991). Delusional manifestation. British Journal of Psychiatry, 159, 83-87.

Hinkle, N.C. (2000). Delusory parasitosis. American Entomologist 46, 17-25.

Ohtaki, N. (1991). Ninety four cases with delusions of parasitosis. Japanese Journal of Dermatology, 101, 439-446.

Rasmussen, J.E. & Voorhees, J.J. (1990). Psychosomatic dermatology. Archives of Dermatology, 126, 90-93.

Nel, M., Schoeman, J.P. & Lobetti, R.G. (2001). Delusions of parasitosis in clients presenting pets for veterinary care. Journal of the South African Veterinary Association, 72, 167-169.

Trabert, W. (1995). 100 years of delusional parasitosis. Meta-analysis of 1,223 case reports. Psychopathology, 28, 238-46

Webb, J.P. (1993). Case histories of individuals with delusions of parasitosis in southern California and a proposed protocol for initiating effective medical assistance. Bulletin of the Society of Vector Ecologists 18, 16-24.

Thumb dine with me: Can adult thumb-sucking be viewed as an addiction?

“When I got to pre-school, I discovered that thumb sucking was not the social norm. Other kids teased me: ‘Only babies suck their thumbs!’ This was terrible news. I didn’t want to be a baby, but there was no way for me to stop doing the only thing in the world that soothed me; the one thing I could do, in a violent home, to comfort myself and feel safe. So I compromised: I stopped sucking my thumb in public…But at home, or during any moment of privacy…my left thumb went automatically into my mouth. Rather than tapering off as I aged, my thumb sucking intensified, and I added a small swatch of cotton blanket to the ritual, rubbing it against my upper lip until it was soft and grey. My parents had split up, and I was moving from place to place with my mother and stepfamily, so nobody really had the energy to monitor my behavior. If anybody did notice and say something to me (‘Stop that, you’re going to ruin your teeth!’), I just popped the thumb out and waited 30 seconds before the coast was clear again” (Janice Erlbaum)

The opening quote is taken from Janice Erlbaum’s blog article “I was an adult thumbsucker” (a habit she managed to kick when she was 26 years old). From Erlbaum’s full account, I wouldn’t class the behaviour as an addiction although depending on what definition of addiction is used, an argument could perhaps be made. I have to admit that adult thumb sucking is something which I have often thought about as someone I know well has sucked her right thumb all her life. She’s now in her early forties and has two completely different shaped thumbs (one ‘normal’ and the other flat and very elongated) as a result of four decades of constant thumb sucking. She also tells me that her upper mouth palate has also changed shape and her thumb fits perfectly into the upper groove in her mouth. She also has a number of little routines she performs while sucking her thumb including the caressing of her eyelashes with her right index finger which when thumb-sucking is close to her eyes. She only ever does it when relaxing (such as when she’s watching television) and has learned not to do it in public. During her junior years and early adolescence, her parents tried to get her to stop, and at one point she was given a substance to coat her thumb in (which tasted disgusting when she put her thumb in her mouth). It didn’t work. She still sucked her thumb and put up with the horrible taste.

Most parents reading this will be aware that thumb-sucking tends to emerge in infancy (although there is some evidence that babies can suck their thumbs inside the womb. For instance, Professor Peter Hepper and his colleagues [Queen’s University, Belfast, Northern Ireland) have followed up children who were known to have sucked their thumbs as fetuses). Constant thumb-sucking is not necessarily problematic but depending on how the thumb is sucked, it can cause protruding teeth and other dental problems such as anterior open bite, malocclusion (i.e., misalignment of teeth or incorrect relation between the teeth of the two dental arches), and mucosal trauma. Other problems include deformity of the thumb (something which I have seen for myself first-hand) and speech problems. Thumb-suckers are also more prone to infections such as impetigo around the mouth (i.e., a highly contagious bacterial infection of the surface layers of the skin, which causes sores and blisters), and paronychia of the thumb (i.e., a skin infection that occurs around the nails). Basically, as children get older, the more of a problem thumb sucking is from a medical perspective. As one review of thumb sucking in the American Family Physician journal concluded:

“Major complications of thumb sucking, usually corrects spontaneously if thumb sucking ceases by six years of age. Thumb sucking in a child less than two years of age requires no treatment. In a three- to four-year-old child, thumb sucking may be secondary to changes in the child’s emotional environment, and treatment should be directed at correcting the underlying problem. Thumb sucking that persists beyond the age of six years should be treated”.

An article on thumb-sucking in Psychology Today by psychologist Dr. Susan Heitler looked at the topic of thumb-sucking. Dr. Heitler had been a thumb-sucker herself until she was nine-years old and had to endure “years of orthodonture” because of her childhood thumb-sucking. Her own daughter was also a thumb-sucker and her dentist told her that “trying to end thumbsucking will do more harm than good”, advice that she was not happy with given her own experiences. In her article, she wrote:

“Looks are hugely important to one’s success in life.  Allowing thumbsucking to damage facial appearance is wrong advice.  By the time a child is four or five, with the habit no longer socially appropriate and permanent teeth coming shortly, the risks of continuing to thumb or finger suck clearly outweigh the benefits…When does a bad habit qualify as an addiction?  Usually it’s a function of how much the habit has become physiologically essential so that people feel craving when it is missing. That definitely happens with thumbsucking”.

Dr. Heitler’s article referred to empirical research that had been carried out on thumb-sucking although none of the main findings had any detail as to who had carried out the work, where the research was published, or what methodologies were employed (apart from very general information). Here are some of the main things she reported:

“In a study with premature infants, researchers found that infants who sucked their thumbs or a pacifier had shorter hospital stays. That was because rhythmic sucking soothed them so that they spent less energy in crying. In addition, sucking re-optimized their heart beats and breathing patterns if they were beginning to get upset…In studies of children who do or do not suck a thumb, finger or pacifier, it turns out that the suckers become emotionally more independent at a younger age. Researchers put a child and mom on one end of a long room. On the far end were appealing toys. The suckers ventured further and played with the toys away from Mom longer than the non-suckers…They just had higher self-confidence in being able to handle independent play, knowing that if they felt stressed they could suck for a bit, feel better, and resume playing on their own. It’s generally not until they become toddlers that the downsides of thumbsucking begin to outweigh the gains. Kids then tend to suck when they are trying to fall asleep, when they bored, when they are idling between activities, or to self-soothe when they are upset”.

One online article on thumb-sucking reports that it is a common activity among infants (30%-40% of those yet to start school) and around 10%-20% of children aged over six years. In a more academic source, Dr. Sherry Ellington and colleagues (in a 2000 issue of the Journal of Applied Behavior Analysis reported that thumb sucking is estimated to occur in 23% to 46% of children aged 1 to 4 years. As with the article by Dr. Heitler, it claims that thumb-sucking may have a psychological benefit for young children as it “allows them to consolidate emotions and handle their stresses”.

In a 1953 paper in the International Journal of Psychoanalysis, the Dr. Donald Winnicot presented his theory of transitional objects and phenomena. Dr. Winnicott compared thumb sucking with the use of external objects such as children’s use of comfort blankets drawing parallels  between the two. He also a claims that childish actions like thumb sucking and objects like cuddly toys are the source of manifold adult behavior, amongst many others sexual fetishism. It is also claimed (particularly by psychodynamic psychologists) that such actions stem back to childhood trauma and that behaviours like thumb-sucking help facilitate the need to feel comforted and secure. Another early longitudinal study by Dr. Marjorie Honzik and Dr. John McKee published in the Journal of Pediatrics reported that after the first year of being born, girls more likely to suck their thumbs than boys. The main reason was speculated that “girls’ greater orality may involve greater pleasure from tactile stimulation”.

There doesn’t appear to be much empirical research on adult thumb sucking. A small 1996 study in the Journal of Clinical Psychiatry led by Dr. F. Castellanous found that in 12 intellectually normal adults with stereotypic movement disorder, eight of them displayed thumb-sucking and/or rocking behaviour (and 11 of them had an affective anxiety disorder suggesting that behaviours such as thumb-sucking may be engaged in to help reduce anxiety). A 2008 literature review by Dr Orlando Tanaka and colleagues in the American Journal of Orthodontics and Dentofacial Orthopedics reported some evidence that thumb-sucking might turn into nail biting. This might explain why there is such a seemingly low prevalence of thumb-sucking in adults. All the evidence suggests that thumb sucking in adults is not an addiction but in some people may be symptomatic of other underlying disorders.

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

Further reading

Articles 2day (2012). Tic disorder and thumb sucking. July 2012. Located at: http://www.articles2day.org/2012/07/tic-disorder-and-thumb-sucking-other.html

Batista, E. (2012). Adult thumb sucking, January 12. Located at: http://www.edbatista.com/2012/01/adult-thumb-sucking.html

Castellanous, F.X., Ritchie, G.F., Marsh, W.L. & Rapoport, J.L. (1996). DSM-IV stereotypic movement disorder: persistence of stereotypies of infancy in intellectually normal adolescents and adults. Journal of Clinical Psychiatry, 57, 116-122.

Ellington, S.A., Miltenberger, R.G., Stricker, J.M., Garlinghouse, M.A., Roberts, J. & Galensky, T.I. (2000). Analysis and treatment of finger sucking. Journal of Applied Behavioral Analysis, 33, 41-52.

Erlbaum, J. (2012). It happened to me: I was an adult thumb sucker. August 2. Located at: http://www.xojane.com/it-happened-to-me/it-happened-me-i-was-adult-thumbsucker

Friman, P. C. (1987). Thumb sucking in childhood. Feelings and Their Medical Significance, 29, 11-14.

Heitler, S. (2012). Lessons from thumbsucking, the earliest addiction. Psychology Today, January 26. Located at: http://www.psychologytoday.com/blog/resolution-not-conflict/201201/lessons-thumbsucking-the-earliest-addiction

Hepper, P., Wells, D.L. & Lynch, C. (2004). Prenatal thumbsucking is related to postnatal handedness. Neuropsychologia, 43, 313-315.

Honzik, M.P. & John P. McKee, J.P. (1960). The sex difference in thumb-sucking. Journal of Pediatrics, 61, 726-732.

Leung, A.K. & Robson, W.L. (1991). Thumb sucking. American Family Physician, 44, 1724-1728.

Luke, L. S., & Howard, L. (1983). The effects of thumb sucking on orofacial structures and speech: A review. The Compendium of Continuing Education, 4, 575–579.

Tanaka, O.M., Vitral, R.W.F., Tanaka, G.Y., Pulido A. & Guerrero, & Camargoe, E.S. (2008). Nailbiting, or onychophagia: A special habit. American Journal of Orthodontics and Dentofacial Orthopedics, 134, 305-308.

Winnicott, D. (1953)  Transitional objects and transitional phenomena. International Journal of Psychoanalysis, 34, 89-97.

An eye for an I! A beginner’s guide to auto-enucleation

I have to say that I have no idea what it must be like to lose an eye (i.e., enucleation) but one thing I can’t possibly begin to imagine is what it must like is to remove my own eye (i.e., auto-enucleation). However, there are many clinical and medical reports of people that self-mutilate by stabbing or removing their eye(s). Arguably the most infamous auto-enucleator was Oedipus (in Sophocles’ play) who removed both his eyes after he realized he had unwittingly slept with his own mother and killed his own father.

The psychiatrist Dr. Armando Favazza defines self-mutilation as “the deliberate, direct, non-suicidal destruction or alteration of one’s body tissue”. Dr. Niraj Ahuja and Dr. Adrian Lloyd writing in the Australian and New Zealand Journal of Psychiatry also add that self-mutilation relates to bodily self-damage without wishing to die. Dr. Favazza also believes there are three fundamentally different types of self-mutilation. Enucleation is included in the first type (major self-mutilation) and is the least common. Other forms of self-mutilation in this category include self-castration, penectomy (cutting off one’s own penis) and self-limb amputation.

The second type includes “monotonously repetitive and sometimes rhythmic acts such as head-banging, hitting, and self-biting” (which according to Dr Favazza occur mostly in “moderate to severely mentally retarded persons as well as in cases of autism and Tourette’s syndrome”). The final and most common forms of bodily self-mutilation are moderately superficial and include a compulsive sub-type (e.g., hair-pulling, skin scratching and nail-biting), as well as an episodic/repetitive sub-type (e.g., skin-cutting, skin carving, burning, needle sticking, bone breaking, and wound picking). Many of these self-harming behaviours are a symptom and/or an associated feature in a number of mental personality disorders (e.g., anti-social, borderline, and histrionic personality disorders).

Reports of auto-enucleation in the medical literature were first described in the 1840s. By the early 1900s, the act of removing one’s own eye was actually termed ‘Oedipism’ by Blonel. Auto-enucleation is (of course) exceedingly rare although a couple of studies in the American Journal of Ophthalmology (in 1984) and an analysis of 1,146 enucleations between 1980 and 1990 in the British Journal of Ophthalmology (in 1994) estimated there were 2.8 to 4.3 per 100,000 in the population. However, some papers (such as those by Dr. Favazza) on major self-mutilation have put the incidence as low as one in 4 million.

Enucleators are also known to be at increased risk of further self-harming, and (predictably) are more likely to be living in psychiatric institutions when the auto-enucleation event occurs. They are also at increased risk of removing the second eye at a later date if they didn’t pull out both eyes to start with. A review by Dr. H.R. Krauss and colleagues in a 1984 issue of the Survey of Opthalmology examined 50 cases of self-enucleation and reported that 19 of them had bilateral auto-enucleation (i.e., had removed both of their eyes). A 2007 paper by Dr. Alireza Ghaffari-Nejad and colleagues in the Archives of Iranian Medicine examined the many theories behind self-harming behaviour. They briefly overviewed theories ranging from Fruedian psychoanalytic theory to biologically-based theories. They wrote:

Psychoanalytically self-injurious behaviour has been linked to castration and explained as a process of failure to resolve oedipal complex, repressed impulses, self punishment, focal suicide and aggression turned inwards especially in cases of depression. [Other authors] have postulated interpersonal loss preceding self-injurious behaviour and linked it to rejection sensitivity…Biologically serotonergic depletion preceding self-mutilation has been linked to aggression and depression…Some authors have claimed strong moral, religious and delusional component”

A recent literature review by Dr. Alexander Fan in the journal Psychiatry reported that the vast majority of auto-enucleation cases suffer from psychotic illness (particularly schizophrenia) although other medical and/or psychiatric conditions associated with auto-enucleation include obsessive-compulsive neuroses, severe depression, post-traumatic stress disorders, drug-induced psychoses, bipolar mania. There are also case studies where auto-enucleation has been linked with structural brain lesions, Down Syndrome, epilepsy, neurosyphilis, and Lesch-Nyhan syndrome (juvenile gout). These are similar to other forms of extreme self-mutilation. For instance, self-mutilation in schizophrenia in response to auditory hallucinations has often been described as Van Gogh Syndrome (in reference to the painter’s self-excision of his own left ear)

Other reviews of the psychiatric literature have reported that those who remove their own eyes commonly have delusions (typically sexual and/or religious) and that when asked about motivations for self-harming include reasons such as guilt, atonement, sin, evil, etc. Although some authors have noted that enucleators with religious beliefs are often Christian, other case studies have made reference to other religious faiths (e.g., Muslims). Finally, another paper by Favazza in Hospital and Community Psychiatry concluded that:

“Males in a first episode of a schizophrenic illness that is characterized by delusions associated with a body part or religious delusions are at the greatest risk for MSM [major self-mutilation]. However, MSM of this severity is so rare that it cannot be predicted accurately unless there has been a previous attempt at self-injury or the patient has spoken about wanting to remove or injure an organ. Threatened ocular mutilation deserves special mention because it may occur in a hospital setting, and the case histories suggest that one-to-one nursing is not always be sufficient to prevent enucleation”.

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

Further reading

Berguaa, A., Sperling, W. & Kuchlea M. (2002). Self-enucleation in drug-related psychosis. Ophthalmologica, 216, 269-271.

Eric, J.C., Nevitt, M.P., Hodge, D. &  Ballard, D.J. (1984). Incidence of enucleation in a defined population. American Journal of Ophthalmology, 113, 138-44.

Fan, A.H. (2007). Autoenucleation: A case report and literature review. Psychiatry, October, 60-62.

Favazza, Armando (1998) ‘Introduction’, in Marilee Strong A Bright Red Scream: Self-mutilation and the Language of Pain. New York: Viking.

Favazza, A. & Rosenthal R. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44, 134-140.

Field, H. & Waldfogel, S. (1995). Severe ocular self-injury. General Hospital Psychiatry, 17, 224-227.

Gamulescu, M.A., Serguhn, S., Aigner, J.M., Lohmann, C.P., & Roider J. (2001). Enucleation as a form of self-aggression, two case reports and review of the literature. Klin Monatsbl Augenheilkd, 218, 451-454.

Ghaffari-Nejad, A., Kerdegari, M., & Reihani-Kermani, H. (2007) Self-mutilation of the nose in a schizophrenic patient with Cotard Syndrome. Archives of Iranian Medicine, 10, 540-542.

Gottrau, P., Holbach, L.M. & Nauman, G.O. (1994). Clinicopathological review of 1,146 enucleations (1980-90). British Journal of Ophthalmology, 78, 260-5.

Jeffreys, S. (2000). ‘Body art’ and social status: Cutting, tattooing and piercing from a feminist perspective Feminism and Psychology, 10, 409-429.

Krauss, H., Yee, R. & Foos, R. (1994). Autoenucleation. Survey of Ophthalmology, 29, 179-87.

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