Water feature: A brief look at psychogenic polydipsia, hyponatraemia, and ‘aquaholism’

Over the weekend I went to the cinema with my oldest son to watch Mad Max: Fury Road. The reason I mention this is because King Immortan Joe in the film (who live in a world where water is a scarce commodity) tells his thirsty subjects “Do not become addicted to water, it will take hold of you”. As soon as I got home after the film, I was straight onto Google and Google Scholar to see whether there had been anything written on ‘water addiction’. Unsurprisingly, there were lots of newspaper reports of individuals being ‘addicted’ to water but little in the academic literature. For instance, one American online article told the story of Sasha Kennedy:

“[Sasha] is addicted to water, drinking 25 liters of the stuff a day, far exceeding the USDA Recommended Daily Water Intake of 2.7 liters…What surprised me most was that the condition had a name: Psychogenic polydipsia. It is ‘an uncommon clinical disorder characterized by excessive water-drinking in the absence of a physiologic stimulus to drink’ and is typically found among mental patients on phenothiazine medications. Kennedy appears to be completely sane, although she does experience the dry mouth sensation characteristic of the condition…You’d think drinking so much water would do something to her health, but medical experts confirmed that there is nothing wrong with her. She doesn’t even have hypoatremia, where cells swell due to too much water in the blood. She’s perfectly healthy and her blood isn’t diluted. Then again, her habit started when she was two years old, so maybe her body acclimatized. Her lifestyle, however, is drastically affected by her addiction. She has to go to the toilet 40 times a day and can only get about an hour of sleep every night before having to wake up to drink some water or go to the loo. She carries large bottles of water with her everywhere she goes, and once quit her job because the tap water quality wasn’t up to par”.

Another case was reported by the UK’s Daily Mail who recounted the story of 22-year old “aquaholic” Sarah Schapira who (at the time the article was written) drank seven litres of water every day, and like Sasha above spent a lot of time in the toilet. Schapira stated:

“My argument has always been that water is good for you and helps you to detox. We’ve all been told about the benefits of water, so I drink lots and lots of it, from the minute I wake up to the minute I go to bed. If I don’t have my bottle of water I feel paranoid. And if I try not to drink for an hour, I start to feel dehydrated and I get throbbing headaches. But it has got to the stage where I don’t know how to give it up. It used to make me feel really good and healthy but not any more. I know I ought to cut down but I’m not sure how I can”.

Polydipsia (which in practical terms means drinking more than three litres of water a day) often goes hand-in-hand with hyponatraemia (i.e., low sodium concentration in the blood) and in extreme cases can lead to excessive water drinkers slipping into a coma. The low levels of sodium causes the brain to swell which in turn constricts the blood supply to the brain when the brain compresses against the skull’s inner surface. Another person interviewed for the Daily Mail story was 26-year-old Rachel Bennett, a marketing agent from North London who drank also drank seven litres of water a day which led to headaches and dizziness. She said:

“My friends used to tease me about the amount I drank, but I dismissed their fears because I always thought it was so good for me. It got to the stage where I felt I couldn’t function without it. If I woke without a bottle of water by my bed, I would feel really paranoid. I couldn’t drink tap water – that tasted awful – instead I drank Evian by the gallon. It’s expensive, too – I could spend over £30 a week on water – but I had got to the stage where I got a huge buzz from drinking so much”.

In researching this article, I was surprised to find dozens and dozens of academic papers on psychogenic polydipsia (PPD). For instance, a paper by Dr. Brian Dundas and colleagues in a 2007 issue of Current Psychiatry Reports noted that PPD is a clinical syndrome characterized by polyuria (constantly going to the toilet) and polydipsia (constantly drinking too much water), and is common among individuals with psychiatric disorders. They also noted that:

“The underlying pathophysiology of this syndrome is unclear, and multiple factors have been implicated, including a hypothalamic defect and adverse medication effects. Hyponatremia in PPD can progress to water intoxication and is characterized by symptoms of confusion, lethargy, and psychosis, and seizures or death. Evaluation of psychiatric patients with polydipsia warrants a comprehensive evaluation for other medical causes of polydipsia, polyuria, hyponatremia”.

A 2000 study in European Psychiatry by Dr. E. Mercier-Guidez and Dr. G. Loas examined water intoxication in 353 French psychiatric inpatients. They reported that water intoxication can lead to irreversible brain damage and that around one-fifth of deaths among schizophrenics below the age of 53 years are caused this way. The study reported that 38 of the psychiatric patients (11%) suffered from polydipsia with one-third of them at risk of water intoxication. They also reported that being polydipsic was significantly associated with being male, a cigarette smoker and celibate. Those with polydipsia were highly prevalent among those with schizophrenia, mental retardation, pervasive developmental disorders and somatic disorders.

A comprehensive review by Dr. Victor Vieweg and Dr. Robert Leadbetter in the journal CNS Drugs examined the polydipsia-hyponatraemia syndrome (PHS). They reported that PHS occurs in approximately 5%-10% of institutionalised, chronically psychotic patients, of which four-fifths have schizophrenia. Major clinical features are polydipsia and dilutional hyponatraemia. Patents with PHS can experience delirium, generalised seizures, coma and death. The main ways to treat such individuals are fluid restriction, daily bodyweight monitoring, behavioural approaches, and supplemental oral sodium chloride administration. However, these interventions can be expensive as they require experienced and dedicated multidisciplinary staff. They also report that:

“A number of pharmacological treatments have been assessed for PHS including the combination of lithium and phenytoin, demeclocycline, propranolol, ACE inhibitors, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors, typical antipsychotic drugs, clozapine and risperidone. Of these agents, the most promising are the combination of lithium and phenytoin, and clozapine…Long term strategies include behavioural interventions and the combination of lithium and phenytoin, and clozapine”.

Unsurprisingly, I found almost nothing on being addicted to water. A 2010 review article on PPD by Dr. D. Hutcheon and Dr. M. Bevilacqua in the Annals of the American Psychotherapy Association claimed:

“One way to assess a patient’s ability to limit polydipsia is to examine their objective reasons why polydipsia is so important in their lives. This can be initiated during psychosocial rehabilitation group meetings held semi-weekly (e.g., two 15-minute sessions per week). In these meetings, many patients have described a euphoric quality associated with polydipsia, although others have admitted to increased irritability. Most patients have noted a desire for stimulation, similar to other substances of abuse such as alcohol or street drugs. Developing an understanding of what influences a patient to develop an addiction for polydipsia can improve management of this dysregulation of fluid intake…During the treatment period in a structured inpatient setting, many patients diagnosed with psychogenic polydipsia, whether falling in the range of mild, moderate, or severe addiction, are unable to sustain a comfortable discharge to an open ward…psychogenic polydipsia can become an addiction with no demonstrable cure if left untreated… Due to the nature of the addiction and potential for self-injurious behavior, treatment requires a milieu that balances maximizing the patients’ dignity with their safety, which demands close scrutiny by the multidisciplinary team”.

I also found an old case study from a 1973 issue of the British Journal of Addiction on ‘water dependence’. This paper reported that the excessive drinking of water can dilute electrolytes in an individual’s brain and cause intoxication. A couple of papers by Dr. Bennett Foddy and Dr. Julian Savulescu have cited this case study in their own writings on addiction. In a 2010 issue of Philosophy, Psychiatry and Psychology, they noted:

“Of course, it can be claimed that a person who is addicted to sugar or water is diseased, and that their brain has changed in such a way as to make their sugar- or water-seeking behavior involuntary. Yet we know how sugar interacts with the brain to form a sensitization effect, and it is identical to how drugs – and sugar – interact with the brain of a non-addicted person. If addictions are formed through a pharmacological process, it is the exact same process that forms a person’s likes and dislikes of any pleasurable stimulus. Terms like ‘addiction’ and ‘dependence’ can reasonably be employed when a person’s likes become particularly strong, but it should be understood that these terms denote a difference in degree, not a difference in kind…The only relevant difference between drugs and sugar is that drugs produce a higher level of brain reward relative to the volume of the dose. It is easier to get addicted to heroin than to sugar, because you can do it by taking a quarter gram at a time. It is very hard to get addicted to water, because you must force down liters of it every day”.

This interesting extract argues that it is theoretically possible for someone to become addicted to water and that there is no real difference to drug addictions in terms of conceptualization and mechanism – just that the sheer amount of water that needs to be drunk to have a negative effect is large and highly unlikely.

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

Further reading

Daily Mail (2005). Aquaholics: Addicted to drinking water. May 16. Located at: http://www.dailymail.co.uk/health/article-348917/Aquaholics-Addicted-drinking-water.html

de Leon, J., Verghese, C., Tracy, J. I., Josiassen, R. C., & Simpson, G. M. (1994). Polydipsia and water intoxication in psychiatric patients: a review of the epidemiological literature. Biological Psychiatry, 35(6), 408-419.

Dundas, B., Harris, M., & Narasimhan, M. (2007). Psychogenic polydipsia review: etiology, differential, and treatment. Current Psychiatry Reports, 9(3), 236-241.

Edelstein, E.L. (1973). A case of water dependence. British Journal of Addiction to Alcohol and Other Drugs, 68, 365–367.

Foddy, B., & Savulescu, J. (2007). Addiction is not an affliction: Addictive desires are merely pleasure-oriented desires. American Journal of Bioethics, 7(1), 29-32

Foddy, B., & Savulescu, J. (2010). A liberal account of addiction. Philosophy, Psychiatry, and Psychology, 17(1), 1-22.

Hutcheon, D., & Bevilacqua, M. (2010). Psychogenic polydipsia: A review of past and current interventions for treating psychiatric inpatients diagnosed with psychogenic polydipsia (PPD). Annals of the American Psychotherapy Association, 13(1). Located at: http://www.biomedsearch.com/article/Psychogenic-polydipsia-review-past-current/222558218.html

Teoh, S.Y. (2012). Woman addicted to water drinks 100 glasses a day. The Mary Sue, July 12. Located at: http://www.themarysue.com/woman-addicted-to-water/#geekosystem

Vieweg, W.V.R., & Leadbetter, R.A. (1997). Polydipsia-Hyponatraemia Syndrome. CNS Drugs, 7(2), 121-138.

Verghese, C., de Leon, J., & Josiassen, R. C. (1996). Problems and progress in the diagnosis and treatment of polydipsia and hyponatremia. Schizophrenia Bulletin, 22(3), 455-464.

Place your bets: Has problem gambling in Great Britain decreased?

In the summer of 2014 I was commissioned to review problem gambling in Great Britain (the fall out of which I wrote about in detail in a previous blog). Earlier last year, a detailed report by Heather Wardle and her colleagues examined gambling behaviour in England and Scotland by combining the 2012 data from the Health Survey for England (HSE; n=8,291 aged 16 years and over) and the 2012 Scottish Health Survey (SHeS; n=4,815). To be included in the final data analysis, participants had to have completed at least one of the gambling participation questions. This resulted in a total sample of 11,774 participants. So what did the research find? Here is a brief summary of the main results:

• Two-thirds of the sample (65%) had gambled in the past year, with men (68%) gambling more than women (62%). As with the British Gambling Prevalence Survey (BGPS), past year participation was greatly influenced by the playing of the bi-weekly National Lottery (lotto) game. Removal of those individuals that only played the National Lottery meant that 43% had gambled during the past year (46% males and 40% females).

• Gambling was more likely to be carried out by younger people (50% among those aged 16-24 years and 52% among those aged 25-34 years).

• The findings were similar to the previous BGPS reports and showed that the most popular forms of gambling were playing the National Lottery (52%; 56% males and 49% females), scratchcards (19%; 19% males and 20% females), other lottery games (14%; 14% both males and females), horse race betting (10%; 12% males and 8% females), machines in a bookmaker (3%; 5% males and 1% females), slot machines (7%; 10% males and 4% females), online betting with a bookmaker (5%; 8% males and 2% females), offline sports betting (5%; 8% males and 1% females), private betting (5%; 8% males and 2% females), casino table games (3%; 5% males and 1% females), offline dog race betting (3%; 4% males and 2% females), online casino, slots and/or bing (3%; 4% males and 2% females), betting exchanges (1%; males 2% and females 0%), poker in pubs and clubs (1%; 2% males and 0% females), spread betting (1%; 1% males and 0% females).

• The only form of gambling (excluding lottery games) where females were more likely to gamble was playing bingo (5%; 7% females and 3% males).

• Most participants gambled on one or two different activities a year (1.7 mean average across the total sample).

• Problem gambling assessed using the Problem Gambling Severity (PGSI) criteria was reported to be 0.4%, with males (0.7%) being significantly more likely to be problem gamblers than females (0.1%). This equates to approximately 180,200 British adults aged 16 years and over.

• Problem gambling assessed using the criteria of the fourth Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was reported to be 0.5%, with males (0.8%) being significantly more likely to be problem gamblers than females (0.1%). This equates to approximately 224,100 British adults aged 16 years and over.

• Using the PGSI screen, problem gambling rates were highest among young men aged 16-24 years (1.7%) and lowest among men aged 65-74 years (0.4%). Using the DSM-IV screen, problem gambling rates were highest among young men aged 16-24 years (2.1%) and lowest among men aged over 74 years (0.4%).

• Problem gambling rates were also examined by type of gambling activity. Results showed that among past year gamblers, problem gambling was highest among spread betting (20.9%), played poker in pubs or clubs (13.2%), bet on other events with a bookmaker (12.9%), bet with a betting exchange (10.6%) and played machines in bookmakers (7.2%).

• The activities with the lowest rates of problem gambling were playing the National Lottery (0.9%) and scratchcards (1.7%).

• Problem gambling rates were highest among individuals that had participated in seven or more activities in the past year (8.6%) and lowest among those that had participated in a single activity (0.1%).

The authors also carried out a latent class analysis and identified seven different types of gambler among both males and females. The male groups comprised:

• Cluster A: non-gamblers (33%)
• Cluster B: National Lottery only gamblers (22%)
• Cluster C: National Lottery and scratchcard gamblers only (20%)
• Cluster D: Minimal, no National Lottery [gambling on 1-2 activities] (9%)
• Cluster E: Moderate [gambling on 3-6 activities] (12%)
• Cluster F: Multiple [gambling on 6-10 activities] (3%)
• Cluster G: multiple, high [gambling on at least 11 activities] (1%).

The female groups comprised:

• Cluster A: non-gamblers (40%)
• Cluster B: National Lottery only gamblers (21%)
• Cluster C: National Lottery and scratchcard gamblers only (7%)
• Cluster D: Minimal, no National Lottery (8%)
• Cluster E: moderate, less varied [2-3 gambling activities, mainly lottery-related] (8%)
• Cluster F: moderate, more varied [2-3 gambling activities but wider range of activities] (6%)
• Cluster G: multiple [gambling on at least four activities] (6%)

Using these groupings, the prevalence of male problem gambling was highest among those in Cluster G: multiple high group (25.0%) followed by Cluster F: multiple group (3.3%) and Cluster E: moderate group (2.6%). The prevalence of problem gambling was lowest among those in the Cluster B; National Lottery Draw only group (0.1%) followed by Cluster C: minimal – lotteries and scratchcards group (0.7%). The prevalence of female problem gambling was highest among those in the Cluster G: multiple group (1.8%) followed by those in Cluster F: moderate – more varied group (0.6%). The number of female gamblers was too low to carry out any further analysis. The report also examined problem gambling (either DSM-IV or PGSI) by gambling activity type.

• The prevalence of problem gambling was highest among spread-bettors (20.9%), poker players in pubs or clubs (13.2%), bettors on events other than sports or horse/dog races (12.9%), betting exchange users (10.6%) and those that played machines in bookmakers (7.2%).

• The lowest problem gambling prevalence rates were among those that played the National Lottery (0.9%) and scratchcards (1.7%).

• These figures are very similar to those found in the 2010 BGPS study although problem gambling among those that played machines in bookmakers was lower (7.2%) than in the 2010 BGPS study (8.8%).

• As with the BGPS 2010 study, the prevalence of problem gambling was highest among those who had participated in seven or more activities in the past year (8.6%) and lowest among those who had taken part in just one activity (0.1%). Furthermore, problem gamblers participated in an average 6.6 activities in the past year.

Given that the same instruments were used to assess problem gambling, the results of the most recent surveys using data combined from the Health Survey for England (HSE) and Scottish Health Survey (SHeS) compared with the most recent British Gambling Prevalence Survey (BGPS) do seem to suggest that problem gambling in Great Britain has decreased over the last few years (from 0.9% to 0.5%). However, Seabury and Wardle again urged caution and noted:

“Comparisons of the combined HSE/SHeS data with the BGPS estimates should be made with caution. While the methods and questions used in each survey were the same, the survey vehicle was not. HSE and SHeS are general population health surveys, whereas the BGPS series was specifically designed to understand gambling behaviour and attitudes to gambling in greater detail. It is widely acknowledged that different survey vehicles can generate different estimates using the same measures because they can appeal to different types of people, with varying patterns of behaviour…Overall, problem gambling rates in Britain appear to be relatively stable, though we caution readers against viewing the combined health survey results as a continuation of the BGPS time series”.

There are other important caveats to take into account including the differences between the two screen tools used in the BGPS, HSE and SHeS studies. Although highly correlated, evidence from all the British surveys suggests that the PGSI and DSM-IV screens capture slightly different groups of problem gamblers. For instance, a 2010 study that I co-authored with Jim Orford, Heather Wardle, and others (in the journal International Gambling Studies) using data from the 2007 BGPS showed that the PGSI may under-estimate certain forms of gambling-related harm (particularly by women) that are more likely to be picked up by some of the DSM-IV items. Our analysis also suggested that the DSM-IV appears to measure two different factors (i.e., gambling-related harm and gambling dependence) rather than a single one. Another important distinction is that the two screens were developed for very different purposes (even though they are attempting to assess the same construct). The PGSI was specifically developed for use in population surveys whereas the DSM-IV was developed with clinical populations in mind. Given these differences, it is therefore unsurprising that national surveys that utilize the screens end up with slightly different results comprising slightly different groups of people.

It also needs stressing (as noted by the authors of most of the national gambling surveys in Great Britain) that the absolute number of problem gamblers identified in any of the surveys published to date has equated to approximately 60 people. To detect any significant differences statistically between any of the studies carried out to date requires very large sample sizes. Given the very low numbers of problem gamblers and the tiny number of pathological gamblers, it is hard to assess with complete accuracy whether there have been any significant changes in problem and pathological gambling between all the published studies over time. Wardle and her colleagues concluded that:

“Overall, based on this evidence, it appears that problem gambling rates in England and Scotland are broadly stable. Whilst problem gambling rates according to either the DSM-IV or the PGSI were higher in 2010, the estimate between 2007 and the health surveys data were similar. Likewise, problem gambling rates according to the DSM-IV and the PGSI individually did not vary statistically between surveys, meaning that they were relatively similar” (p.130).

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

Further reading

Griffiths, M.D. (2014). Problem gambling in Great Britain: A brief review. London: Association of British Bookmakers.

Orford, J., Wardle, H., Griffiths, M.D., Sproston, K. & Erens, B. (2010). PGSI and DSM-IV in the 2007 British Gambling Prevalence Survey: Reliability, item response, factor structure and inter-scale agreement. International Gambling Studies, 10, 31-44.

Seabury, C. & Wardle, H. (2014). Gambling behaviour in England and Scotland. Birmingham: Gambling Commission.

Wardle, H. (2013). Gambling Behaviour. In Rutherford, L., Hinchliffe S., Sharp, C. (Eds.), The Scottish Health Survey: Vol 1: Main report. Edinburgh.

Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.

Wardle, H., & Seabury, C. (2013). Gambling Behaviour. In Craig, R., Mindell, J. (Eds.) Health Survey for England 2012 [Vol 1]. Health, social care and lifestyles. Leeds: Health and Social Care Information Centre.

Wardle, H., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.

Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M. D., Constantine, R., & Pigott, S. (2007). The British Gambling Prevalence Survey 2007. London: National Centre for Social Research.

Wardle, H., Sutton, R., Philo, D., Hussey, D. & Nass, L. (2013). Examining Machine Gambling in the British Gambling Prevalence Survey. Report by NatCen to the Gambling Commission, Birmingham.

Displeasures of the flesh: A brief look at anthropophagolagnia and paraphilic behaviour in serial killers

In previous blogs I have examined the psychology of sexual cannibalism and erotophonophilia (aka ‘lust murder’) as well as an article that I wrote on serial killers that collect their victims’ body parts as ‘trophies’. One very rare sub-type of both sexual cannibalism and erotophonophilia is anthropophagolagnia. This particular type of sexual paraphilia has been defined by Dr Anil Aggrawal as the paraphilia of “rape with cannibalism” and by the Right Diagnosis website as “sexual urges, preferences or fantasies involving raping and then cannibalizing the victim”.

The Listaholic website goes as far to say that anthropophagolagnia is one of the ten “most bizarre sexual fetishes on earth” claiming that serial killer is the “poster boy” for these “twisted” individuals. Other serial killers that might be classed as anthropophagolagniacs include Albert Fish, Peter Kirsten, Ottis Toole and Ed Gein. However, there also appear to be cases of what I would call ‘systematic anthropophagolagnia’ if the extract I found online is true:

“While it is easy to dismiss one case as stemming from some sort of neurological aberrations in the participants, we also see sexualized cannibalism in modern day Africa. In the early 2000s in Congo, rape and cannibalism were reported to coincide sporadically across the region. The claims are backed by a UN investigation into the phenomena…Rebels would go into villages and rape the women and children, then dismember them alive while eating their flesh. There are many reports of family members being forced to eat the flesh of other murdered family members after being raped…The men committing these atrocities do not have any neurological aberrations, they simply have the power to exercise this behavior. While cannibalism has been practiced in Africa as part of spiritual traditions for centuries, sadistic sexualized torture is not part of that tradition. So why add it in? Presumably the rebels didn’t all happen to be born child rapists either, yet raping children is part of their terror campaign and they must be able to achieve an erection to carry out the task, and so it must be assumed they learned to like it”.

Last year, I also read about 40-year old preacher Stephen Tari, the leader of a 6,000-strong cannibal rape cult in Papua New Guinea. He was in prison following his conviction for a brutal rape but escaped (only to be killed by people from his village in retaliation for the cannibalistic rape murders he had committed). As a report in The Independent noted:

“[Tari] had previously been accused of raping, murdering and eating three girls in front of their traumatised mothers…The charismatic cult leader, who wore white robes and is said to have regularly drunk the blood of his ‘flower girls’, quickly returned to his home village of Gal after [a prison] escape, but could only manage six months before killing yet again…It has not yet been established if the murdered woman was killed as part of a blood sacrifice, but it is considered likely as Tari was said to have been attempting to resurrect his cult following the spell in prison”.

Dr. Eric Hickey (in his book Serial Murderers and Their Victims) notes that paraphilic behaviour is very common among those that commit sexual crimes (and that more than one is often present) but that the two activities (sex offending and paraphilias) may be two independent constructs and that one does not necessarily affect the other. In fact he notes that:

“Rather than paraphilia being caused by sexual pathology, they may be better understood as one of many forms of general social deviance…For the male serial killer, the paraphilia engaged in usually has escalated from softer forms to those that are considered not only criminal but violent as well. They range from unusual to incredibly bizarre and disgusting. As paraphilia develop, men affected by them often engage in several over a period of time. Most men who engage in paraphilia often exhibit three or four different forms, some of them simultaneously. For those with violent tendencies, soft paraphilia can quickly lead to experimentation with hardcore paraphilia that often involves the harming of others in sexual ways. For example, some paraphilic offenders prefer to stalk and sexually assault their victims in stores and other public places without getting caught. The thrill of hunting an unsuspecting victim contributes to sexually arousing the offender”.

Hickey asserts that anthropophagolagnia is one of the so-called ‘attack paraphilias’ (as opposed to the ‘preparatory paraphilias’). Attack paraphilias are described by Hickey as being sexually violent (towards other individuals including children in extreme circumstances). Preparatory paraphilias are defined by Hickey as those “that have been found as part of the lust killer’s sexual fantasies and activities” (including those that display anthropophagolagnia). However, Hickey notes that individuals that engage in preparatory paraphilias do not necessarily go on to become serial killers. He then goes on to say:

“The process of sexual fantasy development may include stealing items from victims. Burglary, although generally considered to be a property crime, also is sometimes a property crime for sexual purposes. Stealing underwear, toiletries, hair clippings, photographs, and other personal items provides the offender with souvenirs for him to fantasize over”.

Some of the examples Hickey cites are both revealing and psychologically interesting:

“One offender noted how he would climax each time he entered a victim’s home through a window. The thought of being alone with people sleeping in the house had become deeply eroticized. Another offender likes to break into homes and watch victims sleep. He eventually will touch the victim and will only leave when she begins to scream. He ‘began’ his sexual acting out as a voyeur. This paraphilic process was also examined by Purcell and Arrigo (2001), who note that the process consists of mutually interactive elements: paraphilic stimuli and fantasy; orgasmic conditioning process; and facilitators (drugs, alcohol, and pornography). The probability of the offender harming a victim is extremely high given the progressive nature of his sexual fantasies”.

Along with anthropophagolagnia, other ‘attack paraphilias’ that have been associated with serial killers include amokoscisia (sexual arousal or sexual frenzy from a desire to slash or mutilate other individuals [typically women]), anophelorastia (sexual arousal from defiling or ravaging another individual), biastophilia (sexual arousal from violently raping other individuals; also called raptophilia), dippoldism (sexual arousal from abusing children, typically in the form of spanking and corporal punishment), necrophilia (sexual arousal from having sex with acts with dead individuals), paedophilia (sexual arousal from having sex with minors typically via manipulation and grooming), and sexual sadism (empowerment and sexual arousal derived from inflicting pain and/or injuring other individuals).

The ‘preparatory paraphilias’ that typically precede serial killing and attack paraphilias such as anthropophagolagnia include agonophilia (sexual arousal caused by a sexual partner pretending to struggle), altocalciphilia (sexual arousal from high-heeled shoes), autonecrophilia (sexual arousal by imagining oneself as a dead person), exhibitionism (exposing genitals to inappropriate and/or non-consenting people for sexual arousal), frottage (sexual arousal from rubbing up against the body against a sexual partner or object), gerontophilia (sexual arousal from someone whose age is older and that of a different generation), hebephilia (men that are sexually aroused by aroused by teenagers), kleptolagnia (sexual arousal from stealing), retifism (sexual arousal from shoes), scatophilia (sexual arousal via making telephone calls, using vulgar language, and/or trying to elicit a reaction from the other party), scoptophilia (sexual arousal by watching others [typically engaged in sexual behaviour] without their consent, and more usually referred to as voyeurism), and somnophilia (sexual arousal from fondling strangers in their sleep). The multiplicity of co-existent paraphilias (including anthropophagolagnia) is highlighted by the Wikipedia entry on Jeffrey Dahmer:

“Dahmer readily admitted to having engaged in a number of paraphilic behaviors, including necrophilia, exhibitionism, hebephilia, fetishism, pygmalionism, and erotophonophilia. He is also known to have several partialisms, including anthropophagy (also known as cannibalism). One particular focus of Dahmer’s partialism was the victim’s chest area. By his own admission, what caught his attention to Steven Hicks hitchhiking in 1978 was the fact the youth was bare-chested; he also conceded it was possible that his viewing the exposed chest of Steven Tuomi in 1987 while in a drunken stupor may have led him to unsuccessfully attempt to tear Tuomi’s heart from his chest. Moreover, almost all the murders Dahmer committed from 1990 onwards involved a ritual of posing the victims’ bodies in suggestive positions – many pictures taken prior to dismemberment depict the victims’ bodies with the chest thrust outwards. Dahmer also derived sexual pleasure from the viscera of his victims; he would often masturbate and ejaculate into the body cavity and at other times, literally used the internal organs as a masturbatory aid”.

Almost nothing is known empirically about anthropophagolagnia except that it is very rare and that almost all information about it comes from serial killers that have been caught. Explanations for the development of anthropophagolagnia can only be speculated but are likely to be no different from the development of other paraphilic behaviour. Hickey (citing Irwin Sarason and Barbara Sarason’s Abnormal Psychology textbook) notes five key explanations for the development of paraphilias (reproduced below verbatim):

• Psychodynamic – paraphilic behavior as a manifestation of unresolved conflicts during psychosexual development;
• Behavioral – paraphilia is developed through conditioning, modeling, reinforcement, punishment, and rewards, the same process that normal sexual activity is learned;
• Cognitive – paraphilia become substitutes for appropriate social and sexual functioning or the inability to develop satisfying marital relationships;
• Biological – heredity, prenatal hormone environment, and factors contributing to gender identity can facilitate paraphilic interests. Other explanations are linked to brain malfunctioning and chromosomal abnormalities;
• Interactional – that development of paraphilia is a process that results from psychodynamic, behavioral, cognitive, and biological factors.

As an eclectic, I favour the interactional explanation for the existence of anthropophagolagnia but also believe that the most important influences are the behavioural aspects via classical and operant conditioning processes.

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

Further reading

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

Hall, J. (2013). ‘Black Jesus’ murder: Leader of 6,000-strong cannibal rape cult hacked to death by villagers in Papua New Guinea jungle after killing yet again. The Independent, August 30. Located at: http://www.independent.co.uk/news/world/asia/black-jesus-murder-leader-of-6000strong-cannibal-rape-cult-hacked-to-death-by-villagers-in-papua-new-guinea-jungle-after-killing-yet-again-8791967.html

Hickey, E. W. (Ed.). (2003). Encyclopedia of Murder and Violent Crime. London: Sage Publications

Hickey, E. W. (2010). Serial Murderers and Their Victims (Fifth Edition). Pacific Grove, CA: Brooks/Cole.

Purcell, C., and B. Arrigo. (2001). Explaining paraphilias and lust murder: Toward an integrated model. International Journal of Offender Therapy and Comparative Criminology, 45(1), 6–31.

Sarason, I. G. and B. R. Sarason. (2004). Abnormal Psychology, 11th Edition. Upper Saddle River, N.J.: Prentice Hall.

Wikipedia (2014). Jeffrey Dahmer. Located at: http://en.wikipedia.org/wiki/Jeffrey_Dahmer

Disarray of light: A brief look at ‘chaos addiction’

A few weeks ago, three independent things happened that has led me to writing this article. Firstly, I received an email from one of my blog readers who wrote:

“I’m a recovering addict. I still find that hard to admit even after time in therapy and the support of my loved ones, but to say it out loud can sometimes be a help. One part of my therapy, which really did strike a chord was something called ‘Chaos Addiction’. It was suggested to me that my addictive behaviors were fueled by a need to constantly have things in my life that were ‘in flux’ – to experience the ‘predictably unpredictable’. Looking back over my life, it hit home…I’d love it if you might think about sharing this with your site’s readership”.

Secondly, a couple of days later I was given a CD-R by one of my friends that included the song ‘Addicted to Chaos’ by the group Megadeth (from their 1994 album Youthanasia). Thirdly, a couple of days after that I was watching the film Chasing Lanes where the lead character in the film Doyle Gipson (played by Samuel L Jackson) is told by his Alcoholics Anonymous sponsor (played by William Hurt) that he was ‘addicted to chaos’ rather than alcohol.

I have never come across the term ‘chaos addiction’ prior to the email I was sent. As far as I am aware, there has never been any empirical research on the topic although Dr. Keith Lee did write a 2007 book (Addicted to chaos: The journey from extreme to serene) of his own experiences on the topic. Using case studies, the book examines individuals that have become “addicted to intensity out of the chaos and toward mind/body harmony, higher consciousness, and a deeply spiritual transformation”. More specifically:

“In a culture where the ‘extreme theme’ has become the norm, people are increasingly seduced into believing that intensity equals being alive. When that happens, the mind becomes wired for drama and the soul is starved of meaningful purpose. This type of life may produce heart-pounding excitement, but the absence of this addictive energy can bring about withdrawal, fear, and restlessness that is unbearable”.

In researching this article I came across a number of online articles dealing with ‘addiction to chaos’. The term has been applied to the actress Lindsay Lohan following a television interview with Oprah Winfrey (and the many articles that followed that honed in on her ‘addiction to chaos).

A short piece in Business Week by Clate Mask claimed that it is entrepreneurs that are frequently addicted to chaos (based on his “experiences and observations working with thousands and thousands of entrepreneurs over the years” along with his top three signs he sees as being addicted to chaos: (i) their business life revolves around the in-box, (ii) they can’t step away from the business, (ii) they are strangely proud they have so little free time. Clate then goes on to claim that:

“If you find yourself experiencing these symptoms, you are probably addicted to chaos. Get help. Business ownership should bring you more time, money, and control. If you’re not getting that, make some changes to your mindset and your business systems so you can find the freedom you were looking for when you started your business in the first place”.

However, to me, this appears to be more like addiction to work rather than addiction to chaos (see ‘Further reading’ below for my papers on workaholism).

An online article by Silvia Mordini discussed about her personal experiences and how she now uses yoga to provide grounding and stability in her life. (In fact, there are quite a few papers on treating addictions with yoga including a recent systematic review of randomized control trials by Paul Posadski and his colleagues in the journal Focus on Alternative and Complementary Therapies – see ‘Further reading’ below). As Mordini confessed:

“My past addiction to chaos simply hurt me too much. I got sick of the constant mental tug-o-war with myself.  I’m not interested in feeling impatient with one thought and having to pull or push at the next one. Impatience promotes chaos and doesn’t feel good. The antidote to this is patience. Patience feels good. It feels like a return to mental stability no matter the chaos around us or what other people are thinking or doing…[The grounding that yoga brings] serves us as a simplifying force in order to stabilize our minds. When grounded, we plug back into our best selves and become fully present and balanced. Our energy stabilizes. Once centered, we are able to clearly see the circumstances of our lives. We no longer over-respond or over-worry because the static noise of chaos doesn’t pull us apart”.

She then goes on to provide her readers with five practical ways to promote stability and overcome addiction to chaos: (i) practice yoga, (ii) meditate, (iii) use a mantra (she suggests “I will let go of the need to be needed/I will let go of the need to be accepted/I will let go of the need to be accomplished), unplug from technology, and (v) get your hands and feet dirty (do some gardening, go for a walk on the beach, etc.). Obviously there is no clinical research confirming that these strategies would help overcome ‘chaos addiction’ but engaging in them certainly won’t do anyone any harm.

Another online article (‘Addicted to Chaos’) by addiction counselor Rita Barsky notes that many addicts grew up within dysfunctional families and noted:

“We never felt safe in our family of origin and the only thing we knew for sure was that nothing was for sure. Life was totally unpredictable and we became conditioned to living in chaos. When I talk about chaos in our lives, it was often not the kind that can be seen. In fact, many alcoholic/addict mothers were also super controllers and on the surface, our lives appeared to be perfect. The unsafe and chaotic living conditions of our lives were not visible or obvious to the outside world. Despite the appearance of everything being under control, we experienced continued chaos, developed a tolerance for chaos and I believe became addicted to chaos. I think it is important to say I have never done a scientific experiment to investigate this theory. It is based on observation of numerous alcoholic/addicts and their behavior”.

This was clearly written from experience and appears to have some face validity. Interestingly, Barsky then goes on to say:

“During the recovery process life becomes more manageable and less chaotic. The alcoholic/addict begins to feel a sense of autonomy and safety. A feeling of calm settles over their life. The paradox for the alcoholic/addict is that feeling calm is so unfamiliar it induces anxiety. There is a sense of waiting for the other shoe to drop. When there is a crisis, whether real or perceived, we actually experience a physical exhilaration and it feels remarkably like being active. From there it can be a very short distance to a relapse. Even if we don’t pick up we are not in a sober frame of mind. Addiction to chaos can be very damaging. Once engaged in someone else’s crisis we abandon ourselves and often develop resentments, especially if it is someone we love or are close to. Family chaos is the ‘best’ because it’s so familiar and we can really get off on it. When there is a crisis with family or friends we feel compelled to listen to every sordid detail and/or take action. We are unable to let go, we need to be in the mix even though it is painful and upsetting. It requires tremendous effort to detach and not jump in with both feet to the detriment to our well being”.

I find this account compelling because it’s written by someone that appears to have gone through this herself, and has now applied her therapeutic expertise retrospectively to understand the underlying psychology of what was occurring at the height of the addiction. Another compelling account is at Molly Field’s Yoga Blog.

“My object of desire is Chaos. My therapist told me at the end of my first session ever that I have a Chaos addiction…I’m not kidding: this stuff’s insidious. If it weren’t for my awareness of my ability to lose my temper over little-seeming things (aka scars from my past), I’d never know about the Addiction to Chaos. It’s because I grew up with it, was surrounded by it and trained by some of the world’s finest Chaos foments that I became one myself…My relationship with Chaos had become so much a part of my fabric of being that if I didn’t sense it, I would make it”.

Finally, I’ll leave you with the only tool that I have come across that claims to provide a diagnostic indication of whether someone is addicted to chaos. I need to point out that this came from the website of former psychologist Phil McGraw, the US television host of Dr. Phil. I have reproduced everything below verbatim (so when it says that “you are addicted to chaos” if you endorsed five or more of the ten items, that is the view of Dr. Phil – whenever I have co-developed a scale, I at least add the words “You may have a problem” rather than “You have got a problem”).

“While most people try to avoid drama, research shows that others have figured out how to trigger the body’s stress response, just for the rush. Take the test and find out if you’re creating chaos in your everyday life!

Directions: Answer the following questions ‘True’ or ‘False’

• Do you usually yell and scream to make your point?
• Do you ramp things up to win every argument? 

• If you get sick, do you feel that EVERYONE should know about it?
• 
When you argue, do you ever break things or knock them over? 

• Does being calm or bored sound like the worst thing to you? 

• Do you ever yell at strangers if you feel that they are in your way? 

• Do you hate it when you are not the center of attention? 

• Is there usually a crisis to solve in your life? 

• Do you break up or threaten a break up with a mate often? 

• Are you usually the one who starts fights?

Results: If you answered ‘True’ to five or more of the questions above, you are addicted to chaos”

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

Further reading

Barsky, R. (2007). Addicted to Chaos. A Sober Mind, December 2. Located at: http://asobermind.blogspot.co.uk/2007/12/addicted-to-chaos.html

Field, M. (2012). Recovering from an addiction to chaos. The Yoga Blog, April 7. Located at: http://www.theyogablog.com/recovering-from-addiction/

Griffiths, M.D. (2005). Workaholism is still a useful construct Addiction Research and Theory, 13, 97-100.

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.

Jakub, L. Addicted to chaos: Oprah’s interview with Lindsay Lohan. Hello Giggles, August 19. Located at: http://hellogiggles.com/addicted-to-chaos-oprahs-interview-with-lindsay-lohan

Kramer, L. (2015). Are you addicted to chaos? Recovery.org, January, 15. Located at: http://www.recovery.org/pro/articles/are-you-addicted-to-chaos/

Lee, J.K. (2007). Addicted to chaos: The journey from extreme to serene. Transformational Life Coaching and Consultancy.

Mask, C. (2011). Three signs you’re addicted to chaos. Business Week, March 18. Located at: http://www.businessweek.com/smallbiz/tips/archives/2011/03/three_signs_you_are_addicted_to_chaos.html

Posadzki, P., Choi, J., Lee, M. S., & Ernst, E. (2014). Yoga for addictions: a systematic review of randomised clinical trials. Focus on Alternative and Complementary Therapies, 19(1), 1-8.

Mordini, S. (2013). Are you addicted to chaos and drama? Mind Body Green, January 15. Located at: http://www.mindbodygreen.com/0-7395/are-you-addicted-to-chaos-and-drama.html

More tales of heads: A brief look at suicidal decapitation

In a previous blog, I examined non-suicidal decapitations and said that I would look at suicidal decapitations in a future blog (so this is it). In that previous article, I made reference to a paper by Dr. B. Kumral and colleagues who evaluated medico-legal deaths due to decapitation in the Romanian Journal of Legal Medicine. Their paper confirmed that such deaths were indeed rare events in the civilian population accounting for approximately 0.1% of medico-legal autopsies. However, they also reported that the most common method of suicidal decapitation was people jumping in front of trains. Other suicidal decapitation methods included suicidal hanging, vehicle-assisted ligature suicide, and in extremely rare cases, decapitation by guillotine. They carried out a retrospective study investigating characteristic features of decapitation deaths using data collected a 10-year period in autopsies carried out in Istanbul (Turkey).

“A total of 36,270 forensic autopsies were performed over the period of the study and in 19 cases, the bodies were found to be decapitated (0.05%). The age range of decapitated bodies was 18 to 71 years (average 39.1 years), with a male to female ratio of 13/6. There was only one case of suicide and the way used for suicide was a mechanism like guillotine. In this case, a guillotine-like device designed by male victim had been used for deliberately decapitating the body. The age of the suicide case was 41 years”.

A similar study in South Australia by Dr. R.W. Byard and Dr. J.D. Gilbert investigated the characteristic features of deaths due to decapitation between 1986 and 2002 (published 2004 in the American Journal of Forensic Medicine and Pathology). They reported that suicidal decapitation accounted for less than 1% of total suicides and showed “a striking male predominance”, with the favoured method (as with the Turkish study) being the jumping in front of trains.

A paper published in a 2004 issue of Forensic Science International, headed (no pun intended) by Dr. M. Tsokos analysed the phenomenology and morphology of 10 cases of suicidal decapitation (six male, four female; aged 18-60 years). Eight of the suicides involved decapitation by jumping in front of a train, with the remaining two being suicidal hangings. The paper concluded that:

“In suicidal hanging resulting in complete decapitation, the wound margins were clear-cut with an adjacent sharply demarcated circumferential band-like abrasion zone showing a homogenous width, the latter determined by the thickness of the rope. In decapitations due to railway interference a broad spectrum of pathologic alterations such as the co-existence of irregular, ragged and sharp-edged wound margins, vascular and nervous pathways forming bridges in the depth of the wound and bruising could be observed. In such cases skin abrasion zones were generally not circumferential and showed a heterogenous width. Concerning hanging-related complete decapitations, our findings are well in line with those of other authors, namely that heavy body weight of the suicidal, fall from a great height and in some cases inelastic and/or thin rope material used for the noose are the determining factors decisive for complete decapitation”.

Suicidal decapitations by guillotine are rare but do crop up in the forensic literature. For instance, a paper by Dr. Petr Hejna and colleagues in the Journal of Forensic Sciences reported a case of suicidal decapitation. They described the case of a 31-year old male agricultural machinery technician that had built his own guillotine and killed himself (most likely) as a result of extreme psychological distress caused by the death of his father. They reported that:

“The construction of the guillotine was very interesting and sophisticated. The guillotine-like blade with additional weight was placed in a large metal frame. The movement of the blade was controlled by the frame rails. The steel blade was triggered by a tensioned rubber band after releasing the safety catch”.

Given the man’s occupation, it is perhaps unsurprising that he was able to build his own guillotine. Before killing himself, he tested whether it would work by using the guillotine on animal bones. The death was (obviously) almost immediate because of the severe and dramatic loss of blood. What surprised me more was that there were three other cases in the forensic science literature of suicide by guillotine. Two of these are reported in the German literature (so I was unable to read the original papers and have to rely on the descriptions in the paper by Hejna and colleagues). The first case was published in 1994 by Dr. R. Nowak and Dr. S. Seidl. They reported the case of a 21-year-old man that attempted to kill himself by another self-constructed guillotine. The man initially survived but later died because of his serious neck injury caused by the guillotine blade severing the right carotid artery. The second case (that I did manage to track down) was by Dr. K. Shorrock and published in a 2002 issue of the American Journal of Forensic Medicine and Pathology. As Dr. Shorrock reported:

“A recently widowed man constructed a guillotine in the entrance to his cellar, having previously announced his intention to decapitate himself. A neighbor who saw the device from her house alerted the police. The deceased was found completely decapitated, still holding a pair of pliers that he had used to activate the mechanism”

As in the case reported by Dr. Hejna (above), the functionality of the guillotine was tested (with wood rather than animal bone) and he was also a technical engineer. The third case from 2009 (which again I haven’t read because it was in German) by Dr. J. Sidlo and colleagues involved a 56-year-old male locksmith with large financial problems that constructed a small portable guillotine at his home. He successfully decapitated himself.

Suicidal decapitation by hanging appears to be more common than by guillotine. Another paper by Dr. Hejna (with Dr. M. Bohnert) in a 2013 issue of the Journal of Forensic Sciences examined cases of suicidal decapitation by hanging. Their paper investigated four cases of suicidal hanging (three of complete decapitation and one of incomplete decapitation). More specifically, they analysed the personal, circumstantial, autopsy, and toxicological data in an attempt to define basic characteristics of such extreme injuries. They made special reference to two known types of injury associated with hangings and asphyxiations (‘Simon’s hemorrhage’ – bleedings that are ‘stripe-like hemorrhages on the ventral surface of the intervertebral discs of the lumbar part of the spinal column’, and air embolisms – air bubbles in the blood system). They concluded that:

“The crucial factor for the state of decapitation itself is the kinetic energy of the falling body, the strength of the human neck tissue, and the diameter and elasticity of the used ligature. Results of [our study] suggest Simon’s hemorrhage and air embolism as useful autopsy findings in posthanging beheading cases. Simon’s hemorrhage was demonstrated in three cases of four. The test for air embolism was positive in all four cases”.

An earlier 1999 case study report by Dr. M. Rothschild and Dr. V. Schneider in Forensic Science International described a 47-year old man that committed suicide by hanging himself from an apartment’s staircase bannister and decapitated his head in the process. They reported that in this case, all the conditions conspired to result in decapitation. More specifically, they noted that “complete decapitation can occur in rare cases under extreme conditions (heavy body weight, inelastic and/or thin rope material, fall from a great height)”.

Dr. B.L. Zhu and colleagues also reported a case of suicidal decapitation by hanging in a 2000 issue of the journal Legal Medicine. Here, the suicidal hanging took place on a river bridge. They noted that:

“The torso and the head of the victim, respectively, were found apart in a river approximately 100m and 600m, respectively, downstream from the bridge in two days…Torn ligaments between the atlas and axis accompanied by fractures in the axis at the partes interarticulares were indicative of a traction force combined with anteroflexion of the head by falling from a height, and the radial pressure due to a strong, single twisted nylon rope with a slip knot was considered to have contributed considerably to the subsequent skin laceration with wavy marginal abrasions”.

Reading through some of the literature in this area does make gruesome reading (and if you read the papers themselves, almost all of the case study reports actually feature the immediate post-mortem scene of death photographs). However, my guess is that most suicides that result in decapitation are not planned that way apart from the rare cases of suicide by guillotine. From a psychological point of view, I would be interested to find out how the psychological make-up of a suicidal guillotine user differed from a suicidal train jumper and a suicidal hanger.

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

Further reading

Byard, R. W., & Gilbert, J. D. (2004). Characteristic features of deaths due to decapitation. The American journal of forensic medicine and pathology, 25(2), 129-130

Hejna, P., & Bohnert, M. (2013). Decapitation in suicidal hanging – Vital reaction patterns. Journal of Forensic Sciences, 58(s1), S270-S277.

Hejna, P., Šafr, M., & Zátopková, L. (2012). Suicidal decapitation by guillotine: case report and review of the literature. Journal of forensic sciences, 57(6), 1643-1645.

Kumral, B., Büyük, Y., Gündogmus, Ü. N., Sahın, E., & Sahın, M. F. (2012). Medico-legal evaluation of deaths due to decapitation. Romanian Journal of Legal Medicine, 20, 251-254.

Rashid, A. F., Aggarwal, A. D., Aggarwal, O. P., & Kaur, B. (2012). Accidental decapitation – An urban legend turned true. Egyptian Journal of Forensic Sciences, 2, 112-114.

Nowak, R. & Seidl, S. (1994). Suizid mit einer guillotine. Arch Kriminol, 193, 147-152.

Rothschild, M. A., & Schneider, V. (1999). Decapitation as a result of suicidal hanging. Forensic Science International, 106, 55-62.

Shorrock, K. (2002). Suicidal decapitation by guillotine: case report. The American Journal of Forensic Medicine and Pathology, 23(1), 54-56.

Sidlo, J, Valko, S. & Valent D. (2009). Suizid durch ein ungewçhnliches Hiebinstrument. Rechtsmedizin, 19, 165-167.

Tsokos, M., Türk, E. E., Uchigasaki, S., & Püschel, K. (2004). Pathologic features of suicidal complete decapitations. Forensic Science International, 139(2), 95-102.

Zhu, B. L., Quan, L., Ishida, K., Oritani, S., Taniguchi, M., Fujita, M. Q.,… & Maeda, H. (2000). Decapitation in suicidal hanging – A case report with a review of the literature. Legal Medicine, 2(3), 159-162.

Brain humour: The Ig Nobels are coming to Nottingham Trent (again)

I apologise in advance, but today’s blog is (i) a not-so thinly disguised plug (well, a blatant plug) for a national event that is being hosted by my university on Wednesday 18th March (2015) and (ii) a just a slight updating of a blog I published a couple of years ago when the Ig Nobels last came to NTU. The new blurb I was sent by our local organizer Phil Banyard proclaims:

“The Ig Nobel Prizes honour achievements that first make people laugh, and then make them think. The prizes are intended to celebrate the unusual, honour the imaginative — and spur people’s interest in science, medicine, and technology. The awards are held each year at Harvard University and each award is presented by a Nobel laureate such is the esteem of this event. Over the past few years Marc Abrahams has brought an Ig Nobels tour to the UK in the spring. The tours highlights some of the key awards from the Ig Nobels’ back catalogue and provides a great opportunity to promote science to a wider audience. This year’s programme will feature Marc Abrahams, organiser of the Ig Nobel Prizes, editor of the Annals of Improbable Research, and Guardian columnist, together with a gaggle of Ig Nobel Prize winners and other improbable researchers. The programme will include: Chris McManus (Ig Nobel winner, Scrotal asymmetry in ancient Sculpture and man); Richard Stephens (Ig Nobel winner, The effect of swearing on pain); Richard Webb (Tribute to John Hoyland, the father of Nominative Determinism)”.

If that’s not enough to get you going, I would also like to add that science’s top journal Nature says: “The Ig Nobel awards are arguably the highlight of the scientific calendar” (and who am I to argue?). For those of you who know nothing about the Ig Nobels, they were initiated by one of my favourite journalists, Guardian columnist Marc Abrams. Abrams writes a weekly column for the Guardian called Improbable Research and he is also the editor of the Annals of Improbable Research.

Back in February 2010, I was delighted when Abrams did a whole column on my research into gambling entitled ‘Slot-machine gamblers are hard to pin down: Why are gamblers such a difficult subject for academic study?’ Secretly, I’m very proud that he dedicated a whole column to my research. (In fact, I found out while I was researching the original blog on this topic, is that my research also features in his 2012 book This is Improbable: Cheese String Theory, Magnetic Chickens, and Other WTF Research. Here are some of the things he wrote about my research into gambling:

“It’s hard to get good payoffs from slot machines, yes. But it’s also hard to get good information from slot machine gamblers, and that made things awkward for psychologists Mark Griffiths, of Nottingham Trent University, and Jonathan Parke, of Salford University. They explained how, in a monograph called Slot Machine Gamblers – Why Are They So Hard to Study? Griffiths and Parke published it a few years ago in the Journal of Gambling Issues. ‘We have both spent over 10 years playing in and researching this area,’ they wrote, ‘and we can offer some explanations on why it is so hard to gather reliable and valid data. Here are three from their long list.

• First, gamblers become engrossed in gambling. ‘We have observed that many gamblers will often miss meals and even utilise devices (such as catheters) so that they do not have to take toilet breaks. Given these observations, there is sometimes little chance that we as researchers can persuade them to participate in research’ 
• Second, gamblers like their privacy. They ‘may be dishonest about the extent of their gambling activities to researchers as well as to those close to them. This obviously has implications for the reliability and validity of any data collected.’
• Third, gamblers sometimes notice when a person is spying on them. “The most important aspect of non-participant observation research while monitoring fruit-machine players is the art of being inconspicuous. If the researcher fails to blend in, then slot-machine gamblers soon realise they are being watched and are therefore highly likely to change their behaviour.’

The gambling machines go by many names, ‘fruit machine’ and ‘one-armed bandit’ also being popular. But Griffiths and Parke don’t obsess about nomenclature. The two are giants in their chosen profession. The International Journal of Mental Health and Addiction ran a paean from a researcher who said: ‘In the problem gambling field we don’t exhibit the same adulation as music fans for their idols, but we have our superstars and, for me, Mark Griffiths is one.’

Professor Griffiths is one of the world’s most published scholars on matters relating to the psychology of fruit-machine gamblers, with at least 27 published studies that mention fruit machines in their title. These range from 1994’s appreciative Beating the Fruit Machine: Systems and Ploys Both Legal And Illegal to 1998’s admonitory Fruit Machine Gambling and Criminal Behaviour: Issues for the Judiciary*. Women get special attention (Fruit Machine Addiction in Females: a Case Study), as do youths (Adolescent Gambling on Fruit Machines and several other monographs). There is the humanist perspective (Observing the Social World of Fruit-Machine Playing) as well as that of the biomedical specialist (The Psychobiology of the Near Miss in Fruit Machine Gambling). Griffiths and Parke collaborate often. Strangers to their work might wish to begin by reading the classic The Psychology of the Fruit Machine. Their fruitful publication record reminds every scholar that, even when a subject is difficult to study, persistence and determination can yield a rewarding payoff”.

All I can say is that after re-reading this, I wonder how I can still get my head through the door.

More recently, one of my papers was actually reported by Marc Abrams on his Improbable Research website. More specifically, my case study published in the Archives of Sexual Behavior about eproctophilia (i.e., sexual arousal from flatulence), was given press coverage in over 100 newspaper and magazine stories around the world including those in the UK, Ireland, US, Greece, Italy, Holland, China, and Ghana (e.g., New York Daily News, Huffington Post, Daily Telegraph, Daily Mirror, The Sun, Metro, Times of Malta, Irish Examiner, Asian Image, and Cosmopolitan). However, it was actually Abrams who first reported the story under the headline “Academic Study of a Young Man’s Sexual Attraction to Human Gas”. For those who don’t know, the underlying philosophy of the IR website is to feature “research that makes people laugh and then think”. More specifically, Abrams wrote:

“Professor Mark D Griffiths of Nottingham Trent University has published a remarkable new study. Here’s how we know this study is remarkable:  The university’s press office sent copies of it to many prominent science journalists, remarking that (1) ‘It’s the world’s first paper on eproctophilia – sexual arousal from flatulence’ and (2) ‘Professor Griffiths would be more than happy to talk to you in more detail’. A remarkable number of those journalists immediately sent it on to us at the Annals of Improbable Research. We are, in this blog entry you are reading right now, remarking upon that study. There is more. Lots more. In other respects, too, Professor Griffiths is an expert. So renowned is he that Wikipedia devoted an entire web page to him. One of the many things on which he is an expert is the academic study of gamblers. We have celebrated some of his abundant work on that subject. (We express our thanks, and other emotions, to the many journalists who instinctively decided that they should alert us to the existence of Professor Griffiths’s new line of research.) BONUS (unrelated): The 1998 Ig Nobel Prize for literature was awarded to Dr. Mara Sidoli of Washington, DC, for her illuminating report, ‘Farting as a Defence Against Unspeakable Dread’ [Journal of Analytical Psychology, vol. 41, no. 2, 1996, pp. 165-78.]”

Anyway, if you’d like to go see Marc Abrams in person, here are the further details:

Event: The Ig Nobels: A celebration of Science

Time and date: 6.30 pm, Wednesday 18th March

Location: The Newton Building on the City Campus of the University.

Booking details: The event is free but booking is essential.

Book at: www.ntu.ac.uk/ignobles2015 (direct link here)

Details of their UK events and more information about the Ig Nobels can be found on their website: http://www.improbable.com/improbable-research-shows/complete-schedule/

* I’ve never actually written a paper with this title but I think it’s an inadvertent mix of two or three papers I’ve written with similar titles

 

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

Further reading (i.e., the papers cited by Marc Abrams above)

Griffiths, M.D. (1991). The psychobiology of the near miss in fruit machine gambling. Journal of Psychology, 125, 347-357.

Griffiths, M.D. (1994). Beating the fruit machine: Systems and ploys both legal and illegal. Journal of Gambling Studies, 10, 287-292.

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

Griffiths, M.D. (1996). Observing the social world of fruit-machine playing. Sociology Review, 6(1), 17-18.

Griffiths, M.D. (2003). Fruit machine addiction in females: A case study. Journal of Gambling Issues, 8. Located at: http://www.camh.net/egambling/issue8/clinic/griffiths/index.html.

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

Parke, J. & Griffiths, M.D. (2002). Slot machine gamblers – Why are they so hard to study? Journal of Gambling Issues, 6. Located at: http://jgi.camh.net/doi/full/10.4309/jgi.2002.6.7

Parke, J. & Griffiths, M.D. (2006). The psychology of the fruit machine: The role of structural characteristics (revisited). International Journal of Mental Health and Addiction, 4, 151-179.

Yeoman, T. & Griffiths, M.D. (1996). Adolescent machine gambling and crime (I). Journal of Adolescence, 19, 99-104.

Griffiths, M.D. & Sparrow, P. (1998). Fruit machine addiction and crime. Police Journal, 71, 327-334.

Griffiths, M.D. (2001). Cybercrime: Areas of concern for the judiciary. Justice of the Peace, 165, 296-298.

Played to death: What turns online gaming into a health risk?

Please note that the following article is a slightly extended version of an article that was first published by CNN International

Last month, a 32-year old male gamer was found dead at a Taiwanese Internet café following a non-stop three-day gaming session. This followed the death of another male gamer who died in Taipei at the start of the year following a five-day gaming binge.

While these cases are extremely rare, it does beg the question of why gaming can lead to such excessive behaviour. I have spent nearly three decades studying videogame addiction and there are many studies published in both the medical and psychological literature showing that very excessive gaming can lead to a variety of health problems that range from repetitive strain injuries and obesity, through to auditory and visual hallucinations and addiction. I have to stress that there is lots of scientific research showing the many educational and therapeutic benefits of playing but there is definitely a small minority of gamers that develop problems as a result of gaming overuse.

But what is it that makes gaming so compulsive and addictive for the small minority? For me, addiction boils down to constant reinforcement, or put more simply, being constantly rewarded while playing the game. Gaming rewards can be physiological (such as feeling ‘high’ or getting a ‘buzz’ while playing or beating your personal high score), psychological (such as feeling you have complete control in a specific situation or knowing that your strategic play helped you win), social (such as being congratulated by fellow gamers when doing something well in the game) and, in some cases, financial (such as winning a gaming tournament). Most of these rewards are – at least to some extent – unpredictable. Not knowing when the next reward will come keeps some players in the game. In short, they carry on gaming even though they may not have received an immediate reward. They simply hope that another reward is ‘just around the corner’ and keep on playing.

Added to this is the shift over the last decade from standalone console gaming to massively multiplayer online games where games never end and gamers have to compete and/or collaborate with other gamers in real time (instead of being able to pause the game and come back and play from the point at which the player left it). Many excessive gamers report that they hate logging off and leaving such games. They don’t like it as they don’t know what is going on in the game when they are not online.

The last five years has seen large increase in the number of scientific studies on problematic gaming. In May 2013, the American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). For the first time, the DSM-5 included ‘internet gaming disorder’ (IGD) as a psychological condition that warrants future research. Throughout my research career I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences such as total preoccupation, mood modification, cravings, tolerance, withdrawal symptoms, conflict with work, education and other people, and loss of control. These similarities likely reflect a common etiology of addictive behaviour.

So when does a healthy enthusiasm turn into an addiction? At the simplest level, healthy enthusiams add to life and addictions take away from it. But how much is too much? This is difficult to answer as I know many gamers who play many hours every day without any detrimental effects. The DSM-5 lists nine criteria for IGD. If any gamer endorses five or more of the following criteria they would likely be diagnosed as having IGD: (1) preoccupation with internet games; (2) withdrawal symptoms when internet gaming is taken away; (3) the need to spend increasing amounts of time engaged in internet gaming, (4) unsuccessful attempts to control participation in internet gaming; (5) loss of interest in hobbies and entertainment as a result of, and with the exception of, internet gaming; (6) continued excessive use of internet games despite knowledge of psychosocial problems; (7) deception of family members, therapists, or others regarding the amount of internet gaming; (8) use of the internet gaming to escape or relieve a negative mood;  and (9) loss of a significant relationship, job, or educational or career opportunity because of participation in internet games.

The good news is that only a small minority of gamers suffer form IGD. Most online games are fun and exciting to play. But like any activity that is taken to excess, in a minority of cases the activity can become addictive. Any activity if done for days on end could lead to severe health problems and even death – and gaming is no exception. Instead of demonizing games, we need to educate gamers about the potential dangers of very excessive use.

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

Further reading

Griffiths, M.D. (2014). Gaming addiction in adolescence (revisited). Education and Health, 32, 125-129.

Griffiths, M.D., King, D.L. & Demetrovics, Z. (2014). DSM-5 Internet Gaming Disorder needs a unified approach to assessment. Neuropsychiatry, 4(1), 1-4.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Griffiths, M.D. & Pontes, H.M. (2014). Internet addiction disorder and internet gaming disorder are not the same. Journal of Addiction Research and Therapy, 5: e124. doi:10.4172/2155-6105.1000e124.

King, D.L., Haagsma, M.C., Delfabbro, P.H., Gradisar, M.S.^, Griffiths, M.D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical Psychology Review, 33, 331-342.

Kuss, D.J. & Griffiths, M.D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2, 347-374.

Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction: A systematic review. International Journal of Mental Health and Addiction, 10, 278-296.

Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction in adolescence: A literature review of empirical research. Journal of Behavioral Addictions, 1, 3-22.

Lopez-Fernandez, O., Honrubia-Serrano, M.L., Baguley, T. & Griffiths, M.D. (2014). Pathological video game playing in Spanish and British adolescents: Towards the Internet Gaming Disorder symptomatology. Computers in Human Behavior, 41, 304–312.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Pontes, H., Király, O. Demetrovics, Z. & Griffiths, M.D. (2014). The conceptualisation and measurement of DSM-5 Internet Gaming Disorder: The development of the IGD-20 Test. PLoS ONE, 9(10): e110137. doi:10.1371/journal.pone.0110137.

Spekman, M.L.C., Konijn, E.A, Roelofsma, P.H.M.P. & Griffiths, M.D. (2013). Gaming addiction, definition, and measurement: A large-scale empirical study, Computers in Human Behavior, 29, 2150-2155.

Acting up: A brief look at the ‘Hollywood Phenomenon’ delusion

In a previous blog I briefly examined Delusional Misidentification Syndromes (DMSs). These are arguably some of the strangest mental and neurological syndromes that exist. All DMSs involve a belief by the affected individual that the identity of something (i.e., a person, place, object, etc.) has altered or changed in some way. There are many variants of DMS, and in most cases the delusion is monothematic (i.e., it only concerns one particular topic). The DMSs that are most written about are:

• The Fregoli delusion (individuals who have the belief that more than one person that they have met is the same person in more than one disguise).
• The Capgras delusion (individuals who have the belief that someone (typically a spouse or close relative) has been replaced by an identical-looking imposter.
• Subjective doubles (aka Christodoulou syndrome) (individuals who have the belief that there are (one or more) doubles of themselves [i.e., doppelgangers] that carry out actions and behaviours independently and lead a life of their own.
• Intermetamorphosis: (individuals who have the belief that people in their immediate vicinity change identities with each other but keep the same appearance.

According to Dr. K.W. De Pauw and Dr. T.K. Szulecka in a 1988 issue of the British Journal of Psychiatry, those with DMSs are “more likely to commit violent crimes against persons than those with chronic, undifferentiated psychoses”. In their paper, De Pauw and Szulecka reviewed the literature concerning violence associated with DMSs and reported four case studies of individuals that were “either perpetrators or victims of assaults as a consequence of the syndromes of Fragoli, Intermetamorphosis, Subjective Doubles and Capgras”. After this paper was published, Dr. A.P. Shubsachs and Dr. A. Young responded to the paper (also in the British Journal of Psychiatry) with a short account of two case studies with a “variant of delusional misidentification environment”.

The two cases had a delusion that was described as the ‘Hollywood Phenomenon’ and comprised the belief “that the patient’s environment has been changed to a film or theatre set peopled by actors and in which the patient has a role to play”. (This also appears to be similar to the ‘Truman Show’ Delusion that I described in a previous blog and is “a novel delusion, primarily persecutory in form, in which the patient believes that he is being filmed, and that the films are being broadcast for the entertainment of others”).

Shubsachs and Young asserted that the ‘Hollywood Phenomenon’ (HP) was a symptom rather than a syndrome. They also reported that based on their tow case studies, HP can occur along with atypical Capgras phenomenon, and may result in violence, verbal hostility, and non co-operation. Here are the two case studies in the authors’ own words (taken verbatim from the British Journal of Psychiatry):

• Case 1: “Mr. A, a 22-year-old single Australian man with a history of two admissions for bipolar affective disorder, left Australia in the early stages of a manic episode. On arrival in the UK his condition deteriorated, with elevated mood, decreased sleep, excess energy, and accelerated thoughts. He recognised that he was relapsing and consulted a GP, who arranged an urgent out-patient appointment. Before that appointment he became convinced he was ‘an actor and that everything that was going on was a film’ in which he was the main player. He stole a car which he deliberately crashed because ‘it was a stunt car and I was a stunt man who was supposed to crash it…it was rigged so I wouldn’t get hurt’. He was arrested and later assaulted the police surgeon with what he erroneously believed was a bottle of ‘harmless sugar glass’ causing severe injuries. Mr A. claimed that he, the surgeon, and the police were all play actors and that his actions would have ‘no real consequence’. Remanded in prison for psychiatric reports, he was intermittently violent in response to similar misidentifications until he became euthymic following medication. He was transferred Hospital Order, and on admission had insight into his previous delusions”.
• Case 2: “Miss B. exhibited both a Capgras phenomenon and a ‘Hollywood phenomenon’. She was a single retired midwife in late middle age, living alone. She had had several admissions with a diagnosis of depressive psychosis or schizophrenia. On this occasion she was depressed with early morning wakening, psychomotor retardation, appetite and weight loss, and felt hopeless and worthless. She believed relatives were impostors and was verbally aggressive towards them. She believed that the hospital was a film set peopled by actors, the admitting doctor a film director, and that the purpose of the interview was to obtain a script for the film. While she struggled and was verbally hostile at attempts to detain her, there was no serious violence. She recovered fully after ECT”.

Shubsachs and Young claimed that the HP delusion was both uncommon and under-reported, and that both of the cases that they described involved “affective illness without organic impairment”. They then went on to claim that they didn’t think that the ‘Hollywood Phenomenon’ was “specific for affective disorders” (and asked if other psychiatrists reading their case studies could provide other examples). They concluded that the HP “differs from the superficially similar transient experience in derealisation in that it has a real, not an ‘as if’ quality, is enduring, and has all the features of a delusion including the tendency to be acted upon”.

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

Further reading

Christodoulou G.N. (1986). Delusional Misidentification Syndromes. Basel: Karger.

De Pauw, K. W., & Szulecka, T. K. (1988). Dangerous delusions. Violence and the misidentification syndromes. British Journal of Psychiatry, 152(1), 91-96.

Ellis, H.D., Luauté, J.P. & Retterstøl, N. (1994). Delusional misidentification syndromes. Psychopathology, 27(3-5), 117-120.

Enoch, M.D. & Trethowan, W. (1979). Uncommon Psychiatric Syndromes. Oxford: Butterworth-Heinemann; 1979.

Fusar-Poli, P., Howes, O., Valmaggia, L., & McGuire, P. (2008). ’’Truman’’ signs and vulnerability to psychosis. British Journal of Psychiatry, 193, 168.

Gold, J. & Gold, I. (2012). The “Truman Show” delusion: Psychosis in the global village. Cognitive Neuropsychiatry, 17, 455.

Shubsachs, A.P., & Young, A. (1988). Dangerous delusions: The ‘Hollywood phenomenon’. British Journal of Psychiatry, 152(5), 722-722.

Primal suspects: The psychology of Tears for Fears

Because I am both a psychologist and self-confessed music obsessive, one of the questions I am often asked by my friends is ‘Who is the most psychologically influenced band?’ Based on my own musical tastes, I would have to say Tears for Fears (one of many bands named after something psychological – other contenders based on name alone include Pavlov’s Dog, Therapy?, Primal Scream, Madness, and The Mindbenders, to name a few).

Tears For Fears (TFF) were one of my favourite bands as a teenager and (if my memory serves me) I saw them support The Thompson Twins just as their third single (‘Mad World’) became their first British hit single. TFF were formed in 1981 by Roland Orzabal and Curt Smith after they left the Bath-based band Graduate (mostly remembered for their single ‘Elvis Should Play Ska’ from their debut – and only – LP Acting My Age). They briefly called the band ‘History of Headaches’ but eventually settled on TFF.

TFF’s name was inspired by primal therapy (as was the band Primal Scream). Even from a young age I was well aware of primal therapy as I was – and still am – a massive fan of The Beatles and John Lennon. Lennon underwent primal therapy in 1970 with its’ developer (US psychotherapist Dr. Arthur Janov). In fact, one of the reasons I chose to study psychology at university was because I had read Janov’s first book (The Primal Scream) just because of my love of Lennon’s work. As the Wikipedia entry on primal therapy notes:

“Primal therapy is a trauma-based psychotherapy trauma-based created by Arthur Janov, who argues that neurosis is caused by the repressed pain of childhood trauma. Janov argues that repressed pain can be sequentially brought to conscious awareness and resolved through re-experiencing the incident and fully expressing the resulting pain during therapy. Primal therapy was developed as a means of eliciting the repressed pain; the term Pain is capitalized in discussions of primal therapy when referring to any repressed emotional distress and its purported long-lasting psychological effects. Janov criticizes the talking therapies as they deal primarily with the cerebral cortex and higher-reasoning areas and do not access the source of Pain within the more basic parts of the central nervous system. Primal therapy is used to re-experience childhood pain – i.e., felt rather than conceptual memories – in an attempt to resolve the pain through complete processing and integration, becoming ‘real’. An intended objective of the therapy is to lessen or eliminate the hold early trauma exerts on adult life”.

The Primal Scream book recounts the primal therapy experiences that Janov had with 63 clients during a year-and-a-half period in the late 1960s (and who he claimed were all successfully ‘cured’ using his newly developed therapy). Unlike John Lennon, TFF never underwent primal therapy themselves (but read Janov’s work). It was actually Dr. Janov’s 1980 book Prisoners of Pain (Unlocking The Power Of The Mind To End Suffering) where he claimed “tears as a replacement for fears” (and hence the band’s chosen name). In a 2004 television interview, both Smith and Orzabal said they were disillusioned when they met Janov in the mid-1980s (claiming Janov had become quite “Hollywood” and asking TFF to write a musical based on his work).

Both Smith and Orzabal claimed to have had unhappy childhoods that led them to the work of Dr. Janov (they were too poor – unlike Lennon – to actually have primal therapy and described having such therapy as “an aspiration”). Most of their songs directly or indirectly referenced primal therapy. In fact, I would go as far as to say that the whole of their first album The Hurting was a concept LP. Orzabal claimed that “writing the title track was a strange piece of psychic osmosis…I had an acoustic guitar in my hand at the time and played [Curt] what he was describing: that’s how ‘The Hurting’ was written, and we knew for a long time it was the right name for our first album”.

A quick look at the album’s song titles shows how influenced they had been by primal therapy (such as the title track, ‘The Prisoner’, ‘Mad World’, Ideas As Opiates’, ‘Watch Me Bleed’, ‘Memories Fade’, ‘Start Of The Breakdown’, ‘Pale Shelter (You Don’t Give Me Love’, and ‘Change’). As Paul Sinclair notes in his sleeve notes for the latest box-set reissue:

“Like all great art, ‘The Hurting’ connects. The emotion grabs hold of your heart and gives it a squeeze. The Primal Therapy and Janov influence provide a satisfying consistency, and the band are comfortable in using the ‘C’ word [concept] in reference to ‘The Hurting’…[Orzabal adds] It’s a very consistent album with its own personality. There’s a strong message running through it and some of the song titles were taken from Janov’s writing”.

A number of commentators (including Sinclair) have made the observation that the whole album is about the transition between childhood and adulthood. Maybe that’s why I bought it as a teenager. In contrast to lyrics in The Smiths’ ‘Panic’ (“It says nothing to me about my life”), The Hurting “said something to me about my life”. Sinclair also notes:

“Deep analysis of the songs and navel gazing is not a condition of entry. The genius of ‘The Hurting’ is that on one level, it is just an album of great, melodic, hook-filled pop songs…In the end. ‘The Hurting’ was the album that the band needed to make. There was never going to be an alternative debut. The basic idea behind Janov’s Primal Therapy – the impact that the trauma of childhood had on your character as an adult – was the blood running through the veins of the record”.

Of course, TFF haven’t been the only band to have songs and/or an album influenced by psychologists and/or psychological theory (and of course Carl Jung and Sigmund Freud were both on the cover of The Beatles Sgt. Pepper’s Lonely Hearts Club Band). Arguably the most well known LP inspired by Dr. Janov’s therapy was John Lennon’s first ‘proper’ 1970 solo LP (John Lennon/Plastic Ono Band). Other artists have had direct inspiration from Freud (Freudiana by the Alan Parsons Project, the song ‘Psychotherapy’ by Melanie), Jung (Synchronicity by The Police) and Wilhelm Reich (Kate Bush’s single ‘Cloudbusting’ and Patti Smith’s ‘Birdland’). However, I would still contend that TFF were more psychologically influenced as primal therapy was their life philosophy (at least for a number of years).

Most people would probably argue that it was only The Hurting LP that was influenced by Dr. Janov but their later singles off their second LP Songs From The Big Chair are arguably primal therapy-related including ‘Mother’s Talk’ and ‘Shout’ (“Shout, shout, let it all out” could be the mission statement of primal therapy). However, Roland Orzabal claimed that neither were rooted in primal therapy:

“A lot of people think that ‘Shout’ is just another song about primal scream theory continuing the themes of the first album. It is actually more concerned with political protest. It came out in 1984 when a lot of people were still worried about the aftermath of The Cold War and it was basically an encouragement to protest…The song [Mothers Talk] stems from two ideas. One is something that mothers say to their children about pulling faces. They say the child will stay like that when the wind changes. The other idea is inspired by the anti-nuclear cartoon book ‘When The Wind Blows‘ by Raymond Briggs”.

However, ‘The Big Chair’ (B-side to ‘Shout’ and the inspiration for the title of the band’s second LP Songs From The Big Chair) has undeniable psychological roots. The song was inspired by the 1976 film Sybil (based on the 1973 non-fiction book by of the same name by Flora Rheta Schreiber). Sybil is about US psychiatric patient Sybil Dorsett (actually a pseudonym for Shirley Ardell Mason) who was treated for multiple personality disorder (now known as dissociative identity disorder) by her psychoanalyst (Dr. Cornelia Wilbur). ‘The Big Chair’ was in the therapist’s office where Sybil was treated and where she felt safest when talking about her traumatic childhood. Other songs hidden away on TFF B-sides cover aspects of traumatic psychology (‘My Life In The Suicide Ranks’) as well as ‘anti-science’ songs (‘Schrodinger’s Cat’ and ‘Déjà Vu & The Sins of Science’). However, like Christian historian Nathan Albright, I too believe the second LP and later 1986 single ‘Laid So Low’ are psychologically-based:

“Nor did the interest in psychology stop [with ‘The Hurting’]. Tears For Fears’ second album, “Songs From The Big Chair,” are a self-aware “multiple personality” exploration, a conceptual connection that is often forgotten because the hit singles from the album were so successful…Clearly, the musings about power and anger and memory that inform the work of Tears For Fears, the melancholy underpinnings of songs like ‘Watch Me Bleed’ and ‘Laid So Low (Tears Roll Down)’ are fairly easy to recognize, and draw greater meaning the more one knows about the band and its personal histories”.

As the years have passed, TFF’s songs have been less psychological but we are a product of our pasts and I would argue that the band’s output is still likely to be shaped by both their conscious and unconscious ideology. Smith was recently interviewed and he admitted that he still had an interest in various psychologies but that he no longer believed in primal therapy:

“Primal theory blames everything on your parents. So that teenage angst we were going through at the time. Since then, I think I’ve moved on to various different psychologies, but it’s something we’re both interested in. Since then, certainly, I’m not a huge believer in primal theory anymore, but I think that comes from having children”.

Maybe their most recent album (Everybody Loves A Happy Ending) has at last brought the band’s traumatic past to rest. Maybe the music itself became a kind of psychological therapy. As Nathan Albright concluded:

“The fact that [Tears For Fears] have a popular and critically acclaimed body of musical work is itself remarkable, but the fact that their work is heavily influenced by psychology, serving as therapy, serves as an inspiration. Rather than self-medication through drugs or alcohol, the two chose music as therapy, turning their lives into the inspiration for hauntingly beautiful songs in their debut concept album, ‘The Hurting’…And that is the most powerful legacy of Tears For Fears, in providing a way for both commercial viability as well as personal therapy. Many creative people [use] creativity as a way to wrestle with our own demons, and the fact that Tears For Fears were able to do it openly and honestly and sincerely, and successfully gives hope to the rest of us who have chosen to deal with our issues in the light, rather than engaging in false pretense”.

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

Further reading

Albright, N. (2012). Suffer the children: Tears For Fears and musical therapy. Edge Induced Cohesion, May 2. Located at: https://edgeinducedcohesion.wordpress.com/2012/05/02/suffer-the-children-tears-for-fears-and-musical-therapy/

Comaretta, L. (2014). Tears For Fears’ Curt Smith: Back in The Big Chair. Consequence of Sound, November 6. Located at: http://consequenceofsound.net/2014/11/tears-for-fears-curt-smith-back-in-the-big-chair/

Janov, A. (1970). The Primal Scream. New York: Dell Books.

Janov A (1977). Towards a new consciousness. Journal of Psychosomatic Research, 21, 333–339.

Janov, A. (1980). Prisoners of Pain: Unlocking The Power Of The Mind To End Suffering. New York: Anchor Books.

Sinclair, P. (2013). Tears For Fears: The Hurting. (Booklet in the Deluxe Reissue of ‘The Hurting’).

Wikipedia (2015). Arthur Janov. Located at: http://en.wikipedia.org/wiki/Arthur_Janov

Wikipedia (2015). Primal therapy. Located at: http://en.wikipedia.org/wiki/Primal_therapy

Wikipedia (2015). Tears For Fears. Located at: http://en.wikipedia.org/wiki/Tears_for_Fears

Double trouble: Syndrome of subjective doubles‬

In a previous blog on Delusional Misidentification Syndromes, I briefly mentioned the rare syndrome of ‘subjective doubles’ (SSD). Also known as Christodoulou syndrome (after the Greek psychiatrist Dr. George Nikos Christodoulou who first wrote about the syndrome), SSD refers to individuals who have the belief that there are (one or more) doubles of themselves (i.e., doppelgangers) that carry out actions and behaviours independently and lead a life of their own but that have part or sometimes all of the SDD sufferer’s personality. If the sufferer believes that (some or all of) their personality has been transferred to their doppelganger, they may also experience depersonalization (i.e., a problem of self-awareness in which individuals feel they have little control over social situations and feel they are watching themselves act in a vague and dreamlike state. As with other DMSs, subjective doubles syndrome typically arises as a consequence of a mental disorder, brain injury (typically the right central hemisphere) or a neurological disorder. The Wikipedia entry on SSD cited the case of a man who became depersonalized after an operation and was convinced his brain had been placed into someone else’s head and then claimed he recognized the other person.

In the original paper on SSD in a 1978 issue of the American Journal of Psychiatry, Dr. Christodoulou described the case of a young 18-year-old woman who claimed that a female neighbour had (via an “elaborate transformation” involving “metapmophosis”) acquired all of her physical characteristics (“same face, same build, same clothes, same everything’) and become an identical double. To become her double, the female case study believed her doppelganger had used a mask, wig, and special makeup. Her female neighbour wasn’t the only doppelganger as the woman also claimed at least one other woman had become her doppelganger. In rare instances, there may be comorbidity with the Capgras delusion (another misidentification syndrome) and is then referred to ‘subjective Capgras syndrome’. In fact, there are a number of different sub-types of SDD. As the online Dictionary of Hallucinations notes:

“A subdivision of the syndrome of subjective doubles yields a ‘Capgras type’ (characterized by the delusional conviction that unseen doubles are active in the affected individual’s environment), an ‘autoscopic type’ (in which doubles of the self are perceived, ‘projected’ onto other people or objects, as in pareidolia), and a ‘reverse type’ (in which the affected individual believes to be an impostor or to be about to be replaced by someone else). The syndrome of subjective doubles is associated with various psychiatric disorders (notably the group of so-called schizophrenia spectrum disorders) and neurological disorders (notably disorders of the right parieto-temporal lobe). Conceptually and phenomenologically, the syndrome of subjective doubles constitutes the counterpart of a syndrome called ‘mirrored self-misidentification’, in which the affected individual is unable to identify his or her mirror image as oneself”.

Although most sources cite Dr. Christodoulou’s paper in the American Journal of Psychiatry as the first recorded case of SSD, he actually published a paper a year earlier in a 1977 issue of Acta Psychiatrica Belgica on the treatment of the syndrome of doubles. In this paper, Christodoulou used biological methods to treat 20 psychiatric patients with SDD or the related syndromes (Frégoli, intermetamorphosis, Capgras) aged 17 to 67 years of age. His patients were treated with ECT, antidepressants, neuroleptics, and antiepileptics (in some cases given singly whereas others were in combination). It was reported that:

“Results show that (a) the syndrome of doubles responded to various biological treatment methods; (b) in depression, it responded to tricyclic antidepressants; (c) in schizophrenia or organic psychosis, it usually responded to neurolytics; (d) in schizophrenia, it had more chances of responding to trifluoperazine given alone or in association with other psychopharmacological drugs; and (e) in certain cases, combination of antipsychotic treatment with treatment of coexisting organic dysfunctions appeared to be important”.

In another 1978 paper (in the Journal of Nervous and Mental Disease), Dr. Christodoulou described the course and prognosis of 20 patients with the syndrome of doubles (including Capgras syndrome, Fregoli syndrome, intermetamorphosis syndrome, and SDD – and presumably the same cases reported in the 1977 paper). He reported that the onset of the syndromes occurred either synchronously or at a later stage than the onset of the associated psychosis. In seven of the 20 cases, the syndrome failed to remit. In the remaining 13 cases, remission occurred either synchronously with or later than the remission of the basic psychosis. In all cases where there was comorbid depression, the syndromes cleared shortly after the successful treatment of the depressive illness. It was also noted that relapse of the basic psychotic condition in the setting of which the syndrome had originally developed was usually accompanied by the syndrome reappearing. In one of his most recent papers (from a 2009 issue of Current Psychiatry Reports), Christodoulou and three of his colleagues noted that:

“The delusional misidentification syndromes [including SDD] are rare psychopathologic phenomena that occur primarily in the setting of schizophrenic illness, affective disorder, and organic illness. They are grouped together because they often co-occur and interchange, and their basic theme is the concept of the double. They are distinguished as hypoidentifications (Capgras’ syndrome) and hyperidentifications (the other three syndromes [including SDD]).,,[We] propose that the appearance of these syndromes must alert physicians to investigate the existence of possible organic contributions”.

Compared to other misidentification syndromes, SDD appears to be relatively rare and is often comorbid with other similar conditions. For instance, in a 1986 issue of the Journal of Clinical Psychiatry, Dr. A.B. Joseph described the case of a 30-year old white male who had SDD along with paranoid schizophrenia, Cotard’s syndrome, Capgras delusion, and palinopsia (visual perseveration). Joseph concluded that cerebral dysfunctions in the confluence of the parietal, temporal, and occipital regions of the brain appeared to account for the disorders. Similarly, a 1996 paper in the journal Australasian Psychiatry, Dr. S. Atwal and Dr. M. Khan reported an unusual case of Capgras syndrome coexisting with three related syndromes (Fregoli syndrome, intermetamorphosis syndrome, and SDD).

In a more recent 1991 paper in the journal Psychological Medicine, Dr. H. Forstl and his colleagues examined the psychiatric, neurological and medical aspects of 260 cases suffering misidentification syndromes. Among the sample SDD was relatively rare as 174 cases had a Capgras syndrome misidentifying other persons, 18 a Fregoli syndrome, 11 intermetamorphosis, 17 reduplicative paramnesia and the rest had other forms or combinations of mistaken identification (including SDD). The most common comorbid disorders among those who misidentified themselves or other were schizophrenia (n=127; mostly paranoid schizophrenia), affective disorder (n=29), and organic mental syndromes including dementia (n=46). The authors reported that:

“The misidentification of persons can be a manifestation of any organic or functional psychosis, but the misidentification of place is frequently associated with neurological diseases, predominantly of the right hemisphere. Misidentification syndromes show a great degree of overlap and do not represent distinctive syndromes nor can they be regarded as an expression of a particular disorder. These patients deserve special diagnostic and therapeutic attention because of the possible underlying disorders and their potentially dangerous behaviour”.

Finally, I thought I would leave you with a paper from a 2005 issue of the journal Psychopathology that reported some extreme cases involving delusional misidentification syndromes (DMS) and the danger associated with them. Dr. M. Aziz and his colleagues reported on three cases with histories of paranoid schizophrenia tall of who developed DMSs:

“Two of them acted out on delusional thinking toward their sons. Case 1 managed to kill her son and Case 2 was caught twice trying to choke him. Our case reports suggest that the degree of threat perceived by the patient from the delusionally misidentified object is the most important factor in determining the patient’s response to the delusions. Alcohol and substance intoxication facilitated the patients’ acting out on their delusions, but did not explain the genesis of the delusions. There is a need to continue to study patients with DMS in order to provide opportunity for greater understanding of the psychopathology of DMS”.

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

Further reading

Atwal, S., & Khan, M. H. (1986). Coexistence of Capgras and its related syndromes in a single patient. Australasian Psychiatry, 20, 496-498.

Aziz, M.A., Razik, G.N., & Donn, J.E. (2005). Dangerousness and management of delusional misidentification syndrome. Psychopathology, 38(2), 97-102.

Christodoulou, G.N. (1977). Treatment of the syndrome of doubles. Acta Psychiatrica Belgica, 77(2), 254-259.

Christodoulou, G.N. (1978). Syndrome of subjective doubles. American Journal of Psychiatry, 135, 249-251.

Christodoulou, G.N. (1978). Course and prognosis of the syndrome of doubles. Journal of Nervous and Mental Disease 166, 73-78.

Christodoulou, G.N., Margariti, M., Kontaxakis, V. P., & Christodoulou, N. G. (2009). The delusional misidentification syndromes: strange, fascinating, and instructive. Current Psychiatry Reports, 11(3), 185-189

Dictionary of Hallucinations (2013). Syndrome of subjective doubles. Located at: http://hallucinations.enacademic.com/1828/syndrome_of_subjective_doubles

Enoch, D., Ball, H. (2001). Uncommon Psychiatric Syndromes (Fourth Edition). London: John Wright & Sons.

Forstl, H.A.N.S., Almeida, O. P., Owen, A. M., Burns, A., & Howard, R. (1991). Psychiatric, neurological and medical aspects of misidentification syndromes: A review of 260 cases. Psychological Medicine, 21, 905-910.

Joseph, A.B. (1986). Cotard’s syndrome in a patient with coexistent Capgras’ syndrome, syndrome of subjective doubles, and palinopsia. Journal of Clinical Psychiatry, 47, 605-606.