Coming to a different view: The Masturbation Fantasy Paradox

While researching an article on compulsive masturbation, I quite by chance came across a recent paper published by Wolter Seuntjens in the Journal of Unsolved Questions entitled ‘The Masturbation Fantasy Paradox: An Overlooked Phenomenon?’ (And yes, I too was amazed that there was a journal with such a name, although it colloquially calls itself JUNQ).

Seuntjens noted in his paper that masturbation is an activity that is often accompanied by fantasizing. However, he uses anecdotal evidence and material found in biographic and literary works to suggest some people are completely unable to fantasize about the person they are in love with during masturbation. This he describes as the ‘Masturbation Fantasy Paradox’ (MFP), a “putative phenomenon” that “may be a particular case of a more general principle put forward by Sigmund Freud”. Freud wrote an essay in 1912 concerning the paradoxes of love and desire. More specifically, in ‘On the universal tendency to debasement in the sphere of love’ Freud noted that “where such men love they have no desire and where they desire they cannot love”.

The whole thesis of the paper appears to rests on a few choice selections from autobiographical material supplied by comic actor and broadcaster (and all-round polymath) Stephen Fry, journalist and columnist Dermod Moore, and French writer and poet (and founder of the Surrealist movement) André Breton. More specifically, the extracts chosen by Seuntjens were:

• Extract 1: “Although I was to develop, like every male, into an enthusiastic, ardent and committed masturbator, he was never once, nor ever has been, the subject of a masturbatory fantasy. Many times I tried to cast him in some scene. I was directing for the erotic XXX cinema in my head, but it always happened that some part of me banished him from the set, or else the very sight of him on screen in the coarse porn flick running in my mind had the effect of a gallon of cold water. Sex was to enter our lives, but he was never wank fodder, never” (Stephen Fry in Moab is My Washpot).
• Extract 2: “I have no racy stories about shady events after lights-out in the tent. In fact, having recently discovered masturbation, I found camp frustrating for the lack of opportunity for relief. The fly-infested latrines were the only possible venues, but, unaccountably, self-abuse lost its allure there. However, I was in love with a boy in my patrol. I never really thought about sex with him, but we would roll around on the damp grass in mock combat, laughing and shouting “Help! Homo! Rape!” loudly enough, supposedly, to disguise our covert desire from the others. And from each other” (Dermod Moore in Diary of a Man [about his experience as a Boy Scout]).
• Extract 3: “In 1930, André Breton, while discussing sexuality in the loosely formed group of surrealists, remarked comparably: What do you think about when you masturbate? André Breton: It is accompanied by a series of fleeting images of different women (dream women) or I knew or know but never a woman I have loved”.

These three selections are presented as “direct observations” and then followed by an extract from a book The Ultimate Aphrodisiac by John Hole. In the novel, the book’s main protagonist Norman Ranburn says:

• Extract 4: “It didn’t matter that he might be in love with her. Love meant nothing at his age. Except, he discovered with some fascination, that he didn’t want to besmirch and overlay his vision of her with a dirty wanker’s fantasy”.

Unsurprisingly, Seuntjens notes there is no scientific research into the MFP and also claims there is little research on masturbatory fantasizing more generally. His first port of call are Nancy Friday’s books My Secret Garden (the best selling book on female sexual fantasies) and Men in Love, Men’s Sexual Fantasies: The Triumph of Love Over Rage. Two of Friday’s respondents arguably describe the MFP when they are reported as saying:

• Extract 5: “The funny thing is, when I’m dating someone I really care for, I never fantasize about them…Usually my thoughts center around a man I find fantastically attractive and very nice, i.e., a customer, a stranger on the street, someone I don’t know too well” (‘Beth Anne’).
• Extract 6: “By age twenty, still a virgin, I had had a succession of enchanting teen-age affairs – but since nice girls didn’t have sexual organs and certainly didn’t fuck, I didn’t even attempt to fondle a breast or introduce ‘French’ kissing. I didn’t even feel free to fantasize my latest love for masturbation purposes, usually resorting to her sister or one of her less attractive girl friends instead. One’s love had to be kept on a special Pedestal” (‘Don’).

Friday then goes onto speculate (in her book Forbidden Flowers: More Women’s Sexual Fantasies) that:

“One of the ironies of fantasy is that the hero of our erotic reveries is rarely the man we love. Perhaps it is the very fulfillment and satisfaction we get from him that leaves nothing to the imagination, and so we need these strangers in the night to people our imaginary sexual worlds. They bring us the excitement of the unknown”.

In an arguably more scientific piece of research, Seuntjens made reference to Dr. Brett Kahr’s 2007 book Sex and the Psyche that included reference to his British Sexual Fantasy Research Project comprising 13,553 participants and additional and in-depth face-to-face interviews with a further 122 people. Dr. Kahr made no direct reference to MFP but did note a more negative reason as to why some people do not fantasize about people they love:

“Many of the people whom I interviewed told me that they did not want to fantasize about the partner with whom they had had a row only hours before, the same partner who had spent all their money and had bored them with endless stories about their tedious work colleagues”.

Although the evidence presented by Seuntjens for the MFP was (at best) arguably anecdotal, it doesn’t mean that it doesn’t exist. If it does exist, the obvious question to ask why some people may ‘suffer’ from the MFP while others don’t. As Seuntjens concluded:

“If Freud intended the paradox primarily for the physical act of sex, the Masturbation Fantasy Paradox describes the phenomenon for the mental process of fantasizing. The Masturbation Fantasy Paradox, if it is a genuine phenomenon, may prove to be a special case of the more general paradox of love and desire so pointedly expressed in Freud’s dictum”.

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

Further reading

Freud, S. (1912). On the universal tendency to debasement in the sphere of love’. ‘Contributions to the psychology of love II’ in The Standard Edition of the Complete Psychological Works of Sigmund Freud (1957), Vol. XI, London: Hogarth Press.

Friday, N. (1973). My Secret Garden: Women’s Sexual Fantasies. New York: Pocket Books.

Friday, N. (1975). Forbidden Flowers: More Women’s Sexual Fantasies. London: Arrow Books.

Friday, N. (1980). Men in Love, Men’s Sexual Fantasies: The Triumph of Love Over Rage. London: Arrow Books.

Fry, S. (1997). Moab is My Washpot. London: Hutchinson.

Hole, J. (1996). The Ultimate Aphrodisiac. London: Hodder & Stoughton.

Kahr, B. (2007). Sex and the Psyche. London: Allen Lane

Moore, D. (2005). Diary of a Man. Dublin: Hot Press Books.

Pierre, J. (1992). Investigating Sex – Surrealist Discussions 1928-1932 (translated by Malcom Imrie). New York: Verso.

Seuntjens, W. (2013). The Masturbation Fantasy Paradox: An overlooked phenomenon? Journal of Unsolved Questions, 3(1), 9-12

Banned aid? A brief guide to compulsive helping

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further reading

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

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

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

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

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

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

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

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

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

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

Bad blood: A brief look at zoophagia

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

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

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

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

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

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

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

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

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

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

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

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

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

Further reading

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further reading

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

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

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

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

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

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

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

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

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

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

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

MacLean, C. & Robertson, B.M. (1976). Self enucleation and psychosis. Archives of General Psychiatry, 33, 242-249.

Patil, B. & James, N. (2004). Bilateral self-enucleation of eyes. Eye, 18, 431-432.

Patton N. (2004). Self-inflicted eye injuries: A review. Eye, 18, 867-872.

Rao, K.N. & Begum, S. (1996) Self enucleation in depression; A case report. Indian Journal of Psychiatry, 38, 267-70

Witherspoon, D., Feist, F., Morris, R. & Feist, R. (1989). Ocular self-mutilation. Annals of Ophthalmology, 21, 255-259.

Into the black: Why are we so fascinated by death and dying?

If you type the words “weird addictions” or “strange addictions” into Google, there is one story from 2006 that comes up time and time again. It is usually headlined “Addiction to Funerals” and concerns a Brazilian man called Luis Squarisi. The story claimed that Squarisi (who was 42-years old at the time) had attended every funeral in his hometown of Batatais for more than 20 years. The story also claimed that in order to attend every funeral, Squarisi had given up his job to “feed his addiction to funerals”. He was quoted as saying:

“What set me off was my father’s death in 1983. The first thing I do every morning is to turn on the radio to find out if anyone has died, if I don’t hear it on the radio I call the hospitals and the local funeral home”.

A spokesman from the local São Vicente funeral home where Squarisi lives said: “We don’t want him to go to therapy, everyone expects to see him at the funerals.” If you are regular reader of my blog, it won’t surprise you to learn that I don’t consider Mr. Squarisi’s activity an addiction at all (although the habitual daily ringing of the hospitals and funeral parlour combined with the giving up of his job might potentially be indicators for some types of addiction or compulsion).

However, it did get me thinking about the morbid (and for some almost compulsive) fascination that some people have with death and dying, and whether there were other possible links to addictive, obsessive, and/or compulsive behaviour. Fascination with death and dying is not a recent phenomenon and extends back into ancient history. Historically, many cults have been formed around death gods and figures including Anubis (the jackal-headed Egyptian religious god associated with mummification and the afterlife), Osiris (an Egyptian god usually identified as the god of the afterlife, the underworld and the dead), Hades (the ancient Greek god of the underworld), and Santa Muerte (i.e., “Saint Death”, a sacred and skeletal Mexican figure symbolizing death to remind people of their own mortality).

More recently, people’s fascination with death have included wanting to contact the dead via séances and/or psychics. The greatest evidence of the general public’s fascination with death is the coverage that death gets in the popular media (“if it bleeds, it leads”). There also seems to be an appetite for death as art such as Gunter von Hagen’s Body World’s exhibitions. As US journalist Winda Benedetti put it in her article “Is digging the dead normal or just plain weird?”:

“I have gawked at the skeletons decorating the walls of the Kutna Hora Bone Church in the Czech Republic. I’ve stood transfixed before the towering piles of skulls that mark the Khmer Rouge’s Killing Fields in Cambodia. In Cairo, it was the display of mummified kings and queens that lured me to the Egyptian Museum. And in London, not even the cruel bite of the bitterest winter on record could keep me from standing in a line half a city block long for a peek at “Body Worlds,” a display of dozens of cadavers skinned, dissected and posed for all to see… A new thought occurred: Does my preoccupation with the dead make me a freak? Am I really so different from everyone else? Take a look around. These days it seems the dead are everywhere. Every week on television, actors pretending to be crime-scene investigators pick over the fetid cadavers of the deceased on not just one but three different ‘CSI’ shows. And while these programs are TV-fake, the images of the dead are unflinchingly real”.

While researching this blog, I came across a number of online references about US novelist Charles Dickens being “addicted” to and/or ‘obsessed” with mortuaries and checking out murder scenes. Dickens admitted: “I am dragged by invisible force to the morgue [and] the attraction of repulsion”. He allegedly visited the city mortuary for days at a time observing the dead bodies coming in and watching the morticians who worked on them.

Anyway, the next death-related “addiction” I came across (excluding some recent reports of some people becoming addicted to ingesting embalming fluid!) was “Woman is addicted to eating the ashes of her late husband” from the US television documentary series My Strange Addiction. The woman in question lost her husband following a fatal asthma attack and allegedly developed “a strong compulsion” to keep his ashes by her side at all times that then developed into eating the ashes. She says the ashes eating began when she was first transferring her husband’s cremated remains from a box into an ornamental urn. She accidentally got some of the ashes on her finger and “not wanting to just brush them off, licked them off, starting a habit that has become compulsive”. At the time of the television programme being recorded (and despite the ashes tasting horrible) she had been eating the ashes for two months and had consumed approximately six pounds of the ashes.

Again, I don’t think the woman in question is addicted but the behaviour appears to be an unusual type of pica (i.e., the behaviour in which individuals eat non-nutritive items or substances) and which in some cases has been shown to be compulsive. Other online commentators have speculated that the eating of her husband’s ashes is a way of symbolically holding onto her husband in the easiest way possible.

To me, this ash eating behaviour is reminiscent of one of the ten sub-types of necrophilic activity described by Dr Anil Aggrawal (Maulana Azad Medical College, New Delhi, India). He published a necrophilia typology in a 2009 issue of the Journal of Forensic and Legal Medicine. This new classification of necrophilia included one sub-type that he termed “romantic necrophiles”. According to Aggrawal romantic necrophiles display only “very mild necrophilic tendencies”. This type of necrophile typically comprises people whose loved ones have just died and who do not seem to fully believe or psychologically appreciate that the person they love is dead. Therefore, the sexual contact may not (in the person’s view) be seen as necrophilic as they still believe the person is alive to them. Aggrawal claims that in some cases, romantic necrophiles may mummify the body (or body parts) of their partner. The necrophilic activity is typically short-lived and is something that stops once the person fully accepts that their loved one is dead.

Back in the 18^th century, Martin Schurig in his book Spermatologia, described the case of a Belgian woman, who secretly cut off her husband’s penis he died and treasured it as a sacred relic in a silver casket. This was then turned into a powder and described it is an efficacious medicine. The sexologist, Havelock Ellis, cited the case of a French woman who embalmed and perfumed her dead husband’s genitals and preserved them in a gold casket. Obviously the women who ate her husband’s ashes did not do it for anything sexual but all these cases kept some embodiment of their loved ones in order, as Dr Aggrawal might argue: “to fill up a psychosexual vacuum that their death has caused”.

Maybe the internet will start to fuel the sexual side of death? I’ll leave you with two confessions I came across on the internet. They may – of course – not be in any way representative, but they do seem to suggest that some people out there are fascinated by the sexual macabre:

“I have an addiction to dead bodies. The site of gore porn really turns me on. How should I satisfy my sexual fantasies?”

“I’m 15 years old – female, and I love looking and reading about murder cases and I’m addicted to looking at pictures of murder victims on the internet. I’ve seen ‘3 guys one hammer’ and it didn’t disturb me at all. When I see people I look at them and I can picture in my mind how I could kill them (even if I don’t know them or they’re my friends). Am I disturbed?”

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

Further reading

Aggrawal, A. (2009). A new classification of necrophilia. Journal of Forensic and Legal Medicine, 16, 316-320.

Aggrawal A. (2011). Necrophilia: Forensic and Medico-legal Aspects. Boca Raton: CRC Press.

Benedetti, W. (2006). Is digging the dead normal or just plain weird? Seattle PI, September 29. Located at: http://www.seattlepi.com/lifestyle/article/Is-digging-the-dead-normal-or-just-plain-weird-1216015.php#ixzz1uTvnqX9R

Digital Journal (2006). Man addicted to funerals. November 10. Located at: http://digitaljournal.com/article/48897

Ellis, H.H. (1923). Studies in the Psychology of Sex (Volume V: Erotic Symbolism, The Mechanism of Detumescence, The Psychic State in Pregnancy). Davis FA.

Geekosystem (2011). Woman is addicted to eating the ashes of her late husband. August 9. Located at: http://www.geekosystem.com/woman-eats-husbands-ashes/

Neatorama (2009). Four writers and their strange obsessions. February 7. Located at: http://www.neatorama.com/2009/02/07/four-writers-and-their-strange-obsessions/

Schurig, M. (1720). Spermatologia historico-medica. Frankfurt: Johannis Beckii.

Seaward, A. (2012). Embalming fluid as a drug. Addictionblog.org, April 19. Located at: http://drug.addictionblog.org/embalming-fluid-as-a-drug/

My Strange Addiction: The wonderful world of the weird

In a previous blog, I examined a case of so-called ‘hair dryer dependence’. The source material for this blog came from one of the people who had appeared on the TLC (The Learning Channel) documentary television series My Strange Addiction. Immediately after I had written the blog I was emailed by one of the researchers on the show asking if I could help getting people on the show for the next series (Season 4).

For those who have no idea what I am talking about, My Strange Addiction is a US TV documentary show that features stories about people with unusual behaviours. Very few of the behaviours they have featured so far would be classed as addictions in the way that I define them. However, some of the behaviours are genuine obsessions and/or compulsions while others have not been the focus of any kind of medical and/or psychiatric diagnosis.

So far, the show has featured people with various obsessive-compulsive disorders (some of which I have examined in my blog) including body dysmorphic disorder, pica (the eating of non-food such as paper, mud, glass, metal), exercise bulimia, trichotillomania (compulsive hair pulling), dermatillomania (compulsive skin picking), thumb-sucking, furry fandom, excessive laxative use, urine drinking, paraphilic infantilism (being an adult baby), and dating cars.

MY STRANGE ADDICTION: A CALL FOR PARTICIPANTS

If anyone out there thinks they have an interesting story that My Strange Addiction might like to hear about, the show’s producers would really appreciate any help they can get in reaching people who may be good potential candidates for their TV show.

• Are you currently struggling to overcome a strange obsession, addiction or compulsive behavior that is taking over your life?
• Do you spend countless hours obsessing about something or engaging in behavior that others would say is strange?
• Have you drained all of your finances into this obsession?
• Are your friends and family members concerned about your wellbeing?
• Would you like to regain control of your life and your health?

If you found yourself answering yes to any of these questions, you may qualify to be a participant in a major documentary series that offers professional assistance for those struggling with a strange obsession, compulsion, or addiction.

For consideration, please reply to this advert with your name, age, contact information, and brief explanation of how a strange addiction is taking over your life. You can also contact us directly at 312-467-8145 or 20westcastingteam@gmail.com. All submissions will remain confidential. Thank you for sharing your story.

Postscript: Alternatively, if you would like to tell me your story as part of my own academic research, then feel free to contact me at my academic email address: mark.griffiths@ntu.ac.uk.

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

Further reading and viewing

Griffiths, J. (2011). Review: My Strange Addiction. US Weekly January 25. http://www.usmagazine.com/entertainment/news/review–my-strange-addiction-2011251#ixzz1tYHsItPh

Internet Movie Database. My Strange Addiction. Located at: http://www.imdb.com/title/tt1809014/

My Strange Addiction Official Website. Located at: http://tlc.howstuffworks.com/tv/my-strange-addiction

TV.com. My Strange Addiction. Located at: http://www.tv.com/shows/my-strange-addiction/

Warming Glow. The 10 strangest addictions from  ‘My Strange Addiction’. http://warmingglow.uproxx.com/2012/02/10-strangest-my-strange-addictions#page/1

Wikipedia. My Strange Addiction. Located at: http://en.wikipedia.org/wiki/My_Strange_Addiction

Wikipedia. List of My Strange Addiction episodes. Located at: http://en.wikipedia.org/wiki/List_of_My_Strange_Addiction_episodes

Once a pun a time: Can telling bad jokes be compulsive?

Ever since I can remember, I’ve always had an unhealthy interest in punning. Whether it’s the titles of my blogs or everyday conversation, I can’t seem to resist getting in a pun wherever I can. (I also have a whole section on my CV dedicated to my ‘humorous’ articles including ones that feature nothing but puns). For the purposes of being clear as to what I am actually talking about, a pun – according to the Oxford English Dictionary – is a form of word play that suggests two (or in some cases more) meanings, by exploiting multiple meanings of words, or of similar-sounding words. Author and lexicographer Samuel Johnson went as far as to claim punning the lowest form of humour. In his book ‘Jokes and Their Relation to the Unconscious’, Sigmund Freud asserted that puns are “the lowest form of verbal joke, probably because they are the cheapest – can be made with the least trouble…[and] merely form a sub-species of the group which reaches its peak in the play upon words proper”.

There are a number of references to various forms of ‘compulsive punning’ in the psychological literature. One such name is that of “Foerster’s syndrome”. This was coined by the Hungarian-British author and journalist Arthur Koestler (1905-1983) in a description of the compulsive punning first described by the German neurologist Otfrid Foerster (1873-1941). Back in 1929, Dr Foerster was carrying out brain surgery on a fully conscious male patient who had a brain tumour. When Foerster began to manipulate the patient’s tumor, the patient began a manic outburst of telling one pun after another.

In 1929, a psychiatrist Dr. A.A. Brill reported what he believed were the first cases of Witzelsücht (“punning mania”) in the International Journal of Psychoanalysis. The word ‘Witzelsücht’ comes from the German words ‘witzeln’ (to make jokes or wisecracks), and ‘sücht’ (a yearning or addiction). This rare condition is characterized as a set of neurological symptoms resulting in an uncontrollable tendency to tell puns, inappropriate jokes, and/or pointless or irrelevant stories at inappropriate times. The patient nevertheless finds these utterances intensely amusing. Brill described some of the cases he had come across including a 31-year man with a brain tumour who made puns “about anything and everything”.

This observation by Dr. Brill is not unsurprising as the condition is most commonly seen in those people that have damaged the brain’s orbitofrontal cortex (situated in the frontal lobes of the brain) and often caused by brain trauma, stroke, or a tumour. It is this part of the brain that is most involved in the cognitive processing of decision-making. Old aged people are thought to be most prone to Witzelsucht because of the decreasing amount of grey matter. The condition is also listed in Dorland’s Illustrated Medical Dictionary, which defines Witzelsücht as “a mental condition characteristic of frontal lesions and marked by the making of poor jokes and puns…at which the patient himself is intensely amused”.

It has also been observed that those people with hypomanic disorders are also more prone to engage in excessive punning. During hypomanic epidodes, people’s speech is typically louder and more rapid than usual. Furthermore, it may be full of jokes, puns, plays on words, and irrelevancies. Others have noted that hypomanic episodes may comprise unexplained tearfulness alternating with excessive punning and jocularity.

Neurologist Dr. Kenneth Heilman (University of Florida, USA) says he sees several cases of Witzelsücht each year. “One of the most dramatic cases (that I’ve seen) appeared to be attracted to my reflex hammer. After I checked his deep tendon reflexes and put my hammer down, he picked up the hammer and started to check my reflexes, while giggling”. However, Dr. Heilman (as far as I am aware) has not published any of his findings or clinical observations.

A case study published by Dr. Mario Mendez (University of California at Los Angeles, USA) in a 2005 issue of the Journal of Neuropsychiatry and Clinical Neuroscience claimed that Witzselsucht can occur in those with frontotemporal dementia (FTD). Over a period of two years and as dementia set in, a 57-year-old woman became the life and soul of parties, and would laugh, joke, and sing all the time. During medical examinations, she was highly talkative, animated, and disinhibited. Dr. Mendez reported that she was preoccupied with continuous silly laughter, excitement and frequent childish jokes and puns (i.e., Witzelsücht). Magnetic resonance imaging revealed major atrophy in the anterior temporal lobes of the brain. Citing previous (mostly old German) psychiatric literature, Mendez asserted that FTD is a disorder with a range of neuropsychiatric symptoms that can include Witzelsücht. This includes excessive and inappropriate facetiousness, jokes, and pranks. The woman was given a serotonin selective reuptake inhibitor (SSRI) and other psychoactive medications and her Witzelsucht subsided.

Also in 2005, Ying-Chu Chen and colleagues (National Cheng Kung University Medical Center, Taiwan) published a case report of Witzelsücht and hypersexuality after a stroke. The case involved a 56-year-old man who suffered a stroke. The stroke caused a facial palsy and dysphagia (i.e., difficulty in swallowing). Over the next few days, he became gradually more alert. By the fifth day following the stroke, the man became highly talkative. However, he started telling inappropriate jokes and witticisms, and became euphoric, prankish, and opinionated. He was concerned about his resulting functional deficits, but talked about them in a humorous fashion. Simultaneously with the punning, he also developed hypersexual tendencies, and used erotic words when women were nearby. He also harassed young nurses and other female caregivers. He was unable to correct his inappropriate behaviours. His relatives were very surprised at his inappropriate jokes and the hypersexual behaviours, which were different from that before he had the stroke.

Like the case mentioned previously, he was also given an SSRI as part of his treatment. The use of SSRIs produced a moderate reduction of the man’s aberrant behaviours. Although the physical consequences of the stroke improved, the man’s wife reported that his endless jokes were not only inappropriate in terms of context, but were often obscene. His medication was changed and he was given a noradrenaline reuptake inhibitor. Over the following two months, the inappropriate punning and hypersexual behaviors were rarely noticed.

Finally, (for no other reason than to leave you with a smile on your face), I thought I’d leave you with my top 10 favourite puns that have some connection with the topics of my blogs.

• A good pun is its own reword
• A pessimist’s blood type is always b-negative.
• A Freudian slip is when you say one thing but mean your mother.
• A man needs a mistress just to break the monogamy
• Is a book on voyeurism a peeping tome?
• Dancing cheek-to-cheek is really a form of floor play.
• Does the name Pavlov ring a bell?
• A gossip is someone with a great sense of rumour
• When you dream in colour it’s a pigment of your imagination
• When two egotists meet, it’s an I for an I

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

Further reading

Brill, A.A. (1929). Unconscious insight: Some of its manifestations. International Journal of Psychoanalysis, 10, 145-161.

Chen, Y-C., Tseng, C-Y. & Pai, M-C. (2005). Witzelsucht after right putaminal hemorrhage: A case report. Acta Neurol Taiwan, 14, 195-200.

Freud, S. (1960). Jokes and Their Relation to the Unconsciousness. New York: W.W. Norton

Garfield, E. (1987). The crime of pun-ishment. Essays of an Information Scientist, 10, 174-178.

Griffiths, M.D. (1989). It’s not funny: A case study of ‘punning mania’. The Psychologist: Bulletin of the British Psychological Society, 2, 272.

Koestler, A. (1964). The Act of Creation. New York: Penguin Books, New York.

Mendez, M.F. (2005). Moria and Witzelsucht from frontotemporal dementia. Journal of Neuropsychiatry and Clinical Neuroscience, 17, 429-430.

Shammi, P. & Stuss, D.T. (1999). Humour appreciation: a role of the right frontal lobe. Brain, 122, 657-66.

Compelling evidence: A beginner’s guide to obsessive- compulsive disorders

Most people’s perceptions of obsession and compulsion – if they have never experienced it personally or have encountered it among family and friends – are probably based on television and film characters who have obsessive-compulsive disorders such as Jack Nicholson playing the novelist Melvin Udall in the film As Good As It Gets, or (my own personal favourite) Tony Shalhoub’s playing Adrian Monk in the detective series Monk. Shalhoub’s portrayal of Monk as a dirt phobic, symmetrically obsessed, ex-policeman who never walks on cracks in the pavement appears to show the condition and the effect on his life in a way that everyone can understand and sympathize.

Unsurprisingly and self-evidently, obsessive–compulsive disorder (OCD) is indicated by the presence of either obsessions and/or compulsions and is a clinically heterogeneous condition. In the most recent International Classification of Diseases (10^th Edition) of the World Health Organization, a diagnosis of OCD is indicated if the obsessive and/or compulsive behaviour is present on most days for at least two weeks. To be classed as having OCD, the behaviour(s) must cause significant distress or interfere with a person’s social and/or individual functioning (typically by time wasting). Other psychiatric disorders (e.g., Tourette’s syndrome, depression, schizophrenia) may include OCD behaviours. Furthermore, the World Health Organization ranks OCD as in the top ten most handicapping illnesses as measured by lost income and decreased quality of life.

The psychiatrist Dr David Veale (The Priory Hospital North London) and one the UK’s leading experts on obsessive-compulsive disorders, provides the following two definitions and classic features for compulsions and obsessions:

• Compulsions: These are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observed by others (e.g. checking that a light has been switched off) or a covert mental act that cannot be observed (e.g. repeating a certain phrase repeatedly in one’s mind). Covert compulsions are usually more difficult to resist than overt ones as they are viewed as ‘portable’ (and therefore easier to perform). A compulsion is not pleasurable for the person who experiences it. This differentiates it from impulsive acts such as shopping or gambling that are associated with immediate gratification
• Obsessions: These are defined as unwanted intrusive thoughts, images or urges that repeatedly enters the person’s mind. They are distressing (i.e. the person views the thoughts and/or behaviours as repugnant or inconsistent with their personality) but originate in the person’s mind and not imposed by an outside agency. Unwanted intrusive thoughts, images or urges are almost universal in the general population and their content (e.g., the urge to push someone over, the thought that the oven has been left on, etc.) is indistinguishable from clinical obsessions. However, the difference between a normal intrusive thought and an obsessional thought is the meaning that the person attaches to the occurrence and/or content of the intrusions.

Empirical research suggests that around 2% of the general population suffer from some form of OCD with a roughly equal gender split (although some OCD disorders are more male-based – such as sex and number obsessions – and some are more female based – such as compulsive hand washing). However, prevalence rates are dictated by the screening instruments used (some of which are claimed to over-inflate the problem). However, others claim that the prevalence rates are higher because some sufferers are simply too ashamed to seek the professional help they need.

In a study led by Dr Edna Foa (University of Pennsylvania, USA) on 431 people with OCD, the most common compulsions were checking things such as gas taps (28.8%), cleaning and washing (26.5%), repeating acts (11.1%), mental compulsions such as prayers being constantly repeated (10.9%), ordering, symmetry and/or exactness (5.9%), hoarding and collecting (3.5%), and constant counting (2.1%). The same study found that the most common obsessions were contamination from dirt, germs, viruses, bodily fluids or faeces, chemicals, sticky substances, and dangerous materials (37.8%), fear of harm (23.6%), excessive concern with order or symmetry (10%), obsessions with the body or physical symptoms (7.2%), religious, sacrilegious or blasphemous thoughts (5.9%), sexual thoughts such as being a paedophile or a homosexual (5.5%), urges to hoard useless or worn-out possessions (4.8%), and thoughts of violence or aggression such as stabbing one’s own baby (4.3%).

Similar findings were found in a study led by Dr David Mataix-Cols (Institute of Psychiatry, London) and published in the American Journal of Psychiatry. Following a comprehensive literature review, they reported 12 factor-analytic studies involving more than 2,000 OCD patients were identified. These studies typically showed at least four symptom dimensions. These were (i) symmetry and ordering, (ii) hoarding, (ii) contamination and cleaning, and (iv) obsessions and checking. They concluded that the complex clinical presentation of OCD can be summarized with these few consistent, temporally stable symptom dimensions.

Scientific research has shown that OCD typically develops in early adulthood for females (i.e., in their early twenties) and in late adolescence for males, although children of both sexes can also suffer. Studies using twin and families suggest that genetic factors may also play a role in the expression of OCD although psychological factors are also important in the acquisition, development and maintenance of the disorder. There is also some evidence that OCD is associated with high intelligence. The seriousness and severity of OCD differs from one individual to the next Some people with OCD are able to hide it even from those most close to them. However, more often, OCD seriously affects relationships and can lead to irreconcilable breakdown. It can also disrupt the ability to work or study.

In relation to prognosis, both psychological interventions (e.g., cognitive-behavioural therapy) and pharmacotherapy may lead to a significant decrease in OCD symptoms for typical sufferers. However, symptoms can continue to persist even after treatment. A completely OCD symptom-free period following treatment is relatively uncommon.

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

Further reading

Eddy, K.T., Dutra, L., Bradley, R. & Westen, D. (2004). A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clinical Psychology Review, 24, 1011-1030.

Foa, E.B., Kozak M J, Salkovskis P.M., Coles, M.E. & Amir, N. (1998). The validation of a new obsessive-compulsive disorder scale: The Obsessive-Compulsive Inventory. Psychological Assessment, 10, 206-214.

Hodgson R.J., Budd R. & Griffiths M.D. (2001). Compulsive Behaviours (Chapter 15). In H. Helmchen, F.A. Henn, H. Lauter & N. Sartorious (Eds) Contemporary Psychiatry. Vol. 3 (Specific Psychiatric Disorders). pp.240-250. London: Springer.

Mataix-Cols, D., Conceição do Rosario-Campos, M. & Leckman, J.F. (2005). A multidimensional model of Obsessive-Compulsive Disorder. American Journal of Psychiatry, 162, 228-238.

Rachman, S.J. & Hodgson, R. (1980). Obsessions and Compulsions. Englewood Cliffs, NJ: Prentice Hall.

Veale, D. (2004). Psychopathology of obsessive-compulsive disorder. Psychiatry, 3(6), 65-68.

Tanorexia: Can excessive tanning be an addiction?

Back in June 1997, I appeared as the obligatory “addiction expert” on the BBC television programme ‘Esther’ talking about people who said they were addicted to tanning (and was dubbed by the researchers on the programme as ‘tanorexia’ – a term that – at the time – I had not come across and is still considered slang even by academics researching in the area). I have to admit that none of the case studies on the programme appeared to be addicted to tanning (at least based on my own addiction criteria) but it did at least alert me to the fact that some people at least claimed to be addicted to tanning.

There certainly appeared to be some similarities between the people interviewed and nicotine addiction in the sense that the ‘tanorexics’ knew they were significantly increasing their chances of getting skin cancer as a direct result of their risky behaviour but felt they were unable to stop doing it (similar to nicotine addicts who know they are increasing the probability of various cancers but also feel unable to stop despite knowing the health risks).

Since my appearance on the programme, tanning addiction – typically involving the repeated daily use of sun beds by women – appears to have become a topic for scientific investigation. If memory serves me correctly, most of the people who appeared on the show appeared to be using tanning as a way of raising their self-esteem and to feel better about themselves. Given that when we are exposed to ultraviolet rays from the sun or tanning bed, our bodies produce it’s own mood-inducing morphine-like substances (i.e., endorphins), the idea that someone could become addicted to tanning is not as far-fetched as it could be.

In fact, in a 2006 study published in the Journal of the American Academy of Dermatology by researchers at Wake Forest University Baptist Medical Center (USA) reported that frequent tanners (those who tanned 8-15 times a month; n=8) who took an endorphin blocker (naltrexone) similar to what a person undergoing alcohol or drug withdrawal suffers), whereas infrequent tanners (n=8) experienced no withdrawal symptoms under identical conditions. However, with only 16 participants in total, the results must be treated with some caution.

Symptoms and consequences of tanorexia are alleged to include (i) intense anxiety if sun bed sessions are missed by the tanorexic, (ii) competition among other tanorexics to see who can get the darkest tan, (iii) chronic frustration by the tanorexic that their skin colour is too light, and (iv), the belief by tanoexics that their skin colour is lighter than it actually is (similar to anorexics believing that they are much heavier than they actually are). Some academics claim that tanorexia is not actually the same as tanning addiction, and argue that tanorexics primary motivation is to get a deep coloured tan. However, there is little empirical research to show whether these tanning behaviours are different or part of the same syndrome.

A 2005 study conducted by researchers at the University of Texas (USA) and published in the US journal Archives of Dermatology claimed that more than half of beach lovers could be considered tanning addicts. They then went on to further claim that just over a quarter of the sample (26%) of “sun worshippers” would qualify as having a substance-related disorder if UV light was classed as the substance they crave. Their paper also reported that frequent tanners experienced a “loss of control” over their tanning schedule, and displayed a pattern of addiction similar to smokers and alcoholics.

Another study carried out in 2008 on 400 students and published in the American Journal of Health Behavior reported that 27% of the students were classified as “tanning dependent”. The authors claimed that those classed as being tanning dependent had a number of similarities to substance use, including (i) higher prevalence among youth, (ii) an initial perception that the behavior is image enhancing, (iii) high health risks and disregard for warnings about those risks, and (iv) the activity being mood enhancing. Independent predictors of tanning dependence included ethnicity (i.e., Caucasians more likely than African Americans to be tanning dependent), lack of skin protective behaviours (i.e., those sunbathing without sun cream and experiencing sunburn more likely to be tanning dependent), smoking (smokers more likely to be tanning dependent), and body mass index (obese people less likely to be tanning dependent).

There is also some interesting empirical evidence that in extreme cases, excessive tanning may be an indication of body dysmorphic disorder (BDD), a mental psychological condition where people are obsessively critical of their physique or self-image. A short article published in the Journal of the American Academy of Dermatology reported the case of 11 patients with BDD who used tanning in an attempt to conceal or improve the appearance of a perceived physical defect.

Overall, the evidence as to whether tanorexia and/or tanning addiction exists is limited with the vast majority of empirical data collected by dermatologists rather than psychologists and biologists. As I noted in a previous blog, I am not convinced – yet – that tanorexics experience a real dependence and/or addiction based on the published empirical evidence. However, at least there are research teams (particularly in the US) empirically investigating its existence.

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

Further reading

Heckman, C.J., Egleston, B.L., Wilson, D.B. & Ingersoll, K.S. (2008). A preliminary investigation of the predictors of tanning dependence. American Journal of Health Behavior, 32, 451-464.

Hunter-Yates J., Dufresne, R.G. & Phillips, K.A. (2007). Tanning in body dysmorphic disorder. Journal of the American Academy of Dermatology, 56(5 Supplement), S107-S109.

Kaur, M., Liguori, A., Lang, W., Rapp, S., Fleischer, A., Feldman, S. (2006). Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. Journal of the American Academy of Dermatology, 54, 709-711.

Warthan, M., Uchida, T. & Wagner, R. (2005). UV light tanning as a type of substance-related disorder. Archives of Dermatology, 141, 963-966.