A few weeks ago, my colleagues and I received a lot of media coverage around the world for our latest study on workaholism that was published in the journal PLoS ONE. The study involved researchers from the University of Bergen (Norway) and Yale University USA) and is probably the largest ever study done on the topic as it included 16,426 working Norwegian adults. Our study got a lot of press attention because we examined the associations between workaholism and a number of different psychiatric disorders.
We found that workaholics scored higher on all the psychiatric symptoms than non-workaholics. For instance we found that among those we classed as workaholics (using the Bergen Work Addiction Scale that we published in the Scandinavian Journal of Psychology four years ago and which I talked about in a previous blog), we found that:
- 32.7% met ADHD (attention-deficit/hyperactivity disorder) criteria (12.7 per cent among non-workaholics).
- 25.6% met OCD (obsessive-compulsive disorder) criteria (8.7 per cent among non-workaholics).
- 33.8% met anxiety criteria (11.9 per cent among non-workaholics).
- 8.9% met depression criteria (2.6 per cent among non-workaholics).
These were all statistically significant differences between workaholics and non-workaholics.
I think a lot of people wondered why we looked at the relationship between workaholism and ADHD to begin with. Firstly, research has consistently demonstrated that Attention-Deficit/Hyperactivity Disorder (ADHD) increases the risk of various chemical and non-chemical addictions. ADHD is prevalent in 2.5–5% of the adult population, and is typically manifested by inattentiveness and lack of focus, and/or impulsivity, and excessive physical activity. Individuals with ADHD may often stop working due to their disorder, and may have trouble in getting work health insurance as they are regarded as a risk group. For this reason, we thought that individuals with ADHD may compensate for this by over-working to meet the expectations required to hold down a job. Although this is a contentious issue, there are a number of reasons why ADHD may be relevant to workaholism.
Firstly, we argued that the inattentive nature of individuals with ADHD causes them to spend time beyond the typical working day (i.e., evenings and weekends) to accomplish what is done by their fellow employees within normal working hours (i.e., the compensation hypothesis). In addition, as they may have a hard time concentrating while at work due to environmental noise and distractions (especially office work in open landscape environments), they might find it easier to work after co-workers have left their working environment or work from home. Their attentive shortcomings may also cause them to overly check for errors on the tasks given, since they often experience careless mistakes due to their inattentiveness. This may cause a cycle of procrastination, work binges, exhaustion, and – in some cases – a fear of imperfection. Although ADHD is associated with lack of focus, such individuals often have the ability to hyper-focus once they find something interesting–often being unable to detach themselves from the task.
Secondly, we argued that the impulsive nature of individuals with ADHD causes them to say ‘yes’ and taking on many tasks without them thinking ahead, and taking on more work than they can realistically handle–eventually leading to workaholic levels of activity. Thirdly, we also argued that the hyperactive nature of individuals with ADHD and the need to be constantly active without being able to relax, causes such individuals to keep on working in an attempt to alleviate their restless thoughts and behaviors. Consequently, work stress might act as a stimulant, and they may choose active (and often multiple) jobs with high pressure, deadlines and activity (e.g., media, sales, restaurant work) – where they have the opportunity to multitask and constantly shift between tasks (e.g., Type-A personality behavior).
In line with this, Type-A personality has often been associated – and sometimes used inter-changeably – with workaholism in previous research. This line of reasoning also relates to the workaholic type portrayed by Dr. Bryan Robinson (in his 2014 book Chained to the desk: A guidebook for workaholics, their partners and children, and the clinicians who treat them), in which he actually denoted “attention-deficit workaholics” (who tend to start many projects but become bored easily and need to be stimulated at all times). His description of the “relentless” type also corresponds well with ADHD symptoms (i.e., unstoppable in working fast and meeting deadlines, often with many projects going on simultaneously). In other words, these types may utilize work pressure to obtain focus, constantly seeking stimulation, crisis, and excitement – and therefore like risky jobs.
Finally, people with ADHD are often mistaken as being lazy, irresponsible, or unintelligent because of their difficulties with planning, time management, organizing, and decision-making. Feeling misunderstood might cause individuals with ADHD to push themselves to prove these misconceptions as wrong – and resulting in an excessive and/or compulsive working pattern. Such individuals are often intelligent, but may feel forced or motivated to start up their own business (i.e., entrepreneurs), as they find it troubling to adjust to standard work schedules or organizational boundaries. Previous research has highlighted that workaholism is prevalent among entrepreneurs and the self-employed. Often failing in other aspects of life (e.g., family), work for such individuals may become even more important to them (e.g., self- efficacy). This is why we hypothesized that ADHD symptoms will be positively associated with workaholism in our study (and that is what we found).
Obsessive-Compulsive Disorder (OCD) is another underlying psychiatric disorder that increases the likelihood of developing an addiction. Full-blown OCD occurs in approximately 2-3% of children and adults, and is commonly manifested by intrusive thoughts and repetitive behaviors of checking, obsessing, ordering, hoarding, washing, and/or neutralizing. It has been suggested that addictive behaviors might represent a coping and/or escape mechanism of OCD symptoms, or as an OCD-behavior that eventually becomes an addiction in itself. Previous workaholic typologies such as those described by Dr. Kimberly Scotti and her colleagues in the journal Human Relations have incorporated the ‘compulsive-dependent’ and ‘perfectionistic’ workaholic types, and some empirical studies have demonstrated that obsessive-compulsive traits are present among workaholics. The OCD tendency of having the need to arrange things in a certain way (i.e., a strong need for control) and obsessing over details to the point of paralysis – may predispose workers with such traits to develop workaholic working patterns. Again we found in our study that OCD symptoms were positively related to workaholism.
It has also been reported that other psychiatric disorders such as anxiety and depression may also increase the risk of developing an addiction. Approximately 30% of people will suffer from an anxiety disorder in their lifetime, and 20% will have at least one episode of depression. These conditions often occur simultaneously, as most people who are depressed also experience acute anxiety. Consequently, anxiety and/or depression can lead to addiction, and vice versa. A number of studies have previously reported a link between anxiety, depression, and workaholism. Furthermore, we know that workaholism (in some instances) develops as an attempt to reduce uncomfortable feelings of anxiety and depression. Working hard is praised and honored in modern society, and thus serves as a legitimate behavior for individuals to combat or alleviate negative feelings – and to feel better about themselves and raise their self-esteem. This is why we hypothesized that there would be a positive association between anxiety, depression, and workaholism (and that is what we found). In relation to our study’s findings as a whole, the lead author of our study (Dr. Cecilie Andreassen) told the world’s media:
“Taking work to the extreme may be a sign of deeper psychological or emotional issues. Whether this reflects overlapping genetic vulnerabilities, disorders leading to workaholism or, conversely, workaholism causing such disorders, remain uncertain…Physicians should not take for granted that a seemingly successful workaholic does not have ADHD-related or other clinical features. Their considerations affect both the identification and treatment of these disorders”.
Our findings clearly highlighted the importance of further investigating neurobiological differences related to workaholic behaviour. Finally, in line with our previous research published two years ago (also in the PLoS ONE journal) using a nationally representative sample, 7.8% of the participants in our latest study were classed as workaholics compared to 8.3% in our previous study.
Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Andreassen, C.S., Griffiths, M.D., Hetland, J., Kravina, L., Jensen, F., & Pallesen, S. (2014). The prevalence of workaholism: A survey study in a nationally representative sample of Norwegian employees. PLoS ONE, 9(8): e102446. doi:10.1371/journal.pone.0102446.
Andreassen, C.S., Griffiths, M.D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.
Andreassen, C.S., Griffiths, M.D., Sinha, R., Hetland, J. & Pallesen, S. (2016). The relationships between workaholism and symptoms of psychiatric disorders: A large-scale cross-sectional study. PLoS ONE, 11(5): e0152978. doi:10.1371/journal. pone.0152978.
Griffiths, M.D. (2005). Workaholism is still a useful construct. Addiction Research and Theory, 13, 97-100.
Griffiths, M.D. (2011). Workaholism: A 21st 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.
Karanika-Murray, M., Duncan, N., Pontes, H. & Griffiths, M.D. (2015). Organizational identification, work engagement, and job satisfaction. Journal of Managerial Psychology, 30, 1019-1033.
Karanika-Murray, M., Pontes, H.M., Griffiths, M.D. & Biron, C. (2015). Sickness presenteeism determines job satisfaction via affective-motivational states. Social Science and Medicine, 139, 100-106.
Orosz, G., Dombi, E., Andreassen, C.S., Griffiths, M.D. & Demetrovics, Z. (2016). Analyzing models of work addiction: Single factor and bi-factor models of the Bergen Work Addiction Scale. International Journal of Mental Health and Addiction, in press
Quinones, C. & Griffiths, M.D. (2015). Addiction to work: recommendations for assessment. Journal of Psychosocial Nursing and Mental Health Services, 10, 48-59.
Quinones, C., Griffiths, M.D. & Kakabadse, N. (2016). Compulsive Internet use and workaholism: An exploratory two-wave longitudinal study. Computers in Human Behavior, 60, 492-499.
Robinson, B.E. (2014). Chained to the desk: A guidebook for workaholics, their partners and children, and the clinicians who treat them. New York: New York University Press.
Scotti, K.A., Moore, K.S., & Miceli, M.P. (1997). An exploration of the meaning and consequences of workaholism. Human Relations, 50, 287–314.
Shonin, E., Van Gordon, W., & Griffiths M.D. (2014). The treatment of workaholism with Meditation Awareness Training: A case study. Explore: Journal of Science and Healing, 10, 193-195.
Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.
“Real happiness consists in not what we actually accomplish, but what we think we accomplish” (Charles Green Shaw, American abstract artist)
Ever since I can remember I have always been someone that compiled lists. Back in my youth it was lists of my favourite pop groups, film stars, sports stars, etc. I still make loads of lists but these days they are more likely to be long ‘to do’ lists (in fact, I’ve even written articles on getting the most out of ‘to do’ lists and being organized – see ‘Further reading’ below) or writing articles in the form of lists (in fact, I used to write what I called ‘psychol-lists’ for the British Psychological Society’s in-house magazine The Psychologist). When I make lists I feel more productive, and they are often the spurs to get things done (as long as I actually do the things on the list).
Obviously, list making can be an important activity in the organizational skills of many working individuals. Based on my own observations, most people make lists so they (i) don’t forget things, (ii) don’t procrastinate, (iii) feel in control and focused in what they are doing, (iv) can relieve stress, and (v) can cross things off the list and feel a sense of accomplishment. However, for a minority of people, making lists appears to be obsessive and a mental health issue. In short, there may be a fine line between being organized and being neurotic. From my own personal experience, I know that writing lists can be related to perfectionism. But life isn’t perfect and not completing activities on ‘to do’ lists can raise stress and worry levels. Ironically, the only way some people can deal with this is to make even more lists of things to do.
Obsessive list making is sometimes referred to as glazomania (check out the ‘Manias’ page at The Scorpio Tales website). Online dictionaries tend to define glazomania as either “a passion for list making” or “an unusual fascination with making lists”. However, the term ‘glazomania’ doesn’t appear to be used much academically. I did come across one recent paper in Distinktion: Scandinavian Journal of Social Theory, by Dr. Urs Staeheli that mentioned it:
“Recently, quite a number of coffee-table books have been published that collect different sorts of everyday lists. Some authors even speak of a ‘glazomania‘ (Cagen 2007) – that is, an uncontrolled urge to produce lists and a fascination with list-making”
However, there was no other information provided. I managed to track down the 2007 reference to Sasha Cagen’s book (To-Do List: From Buying Milk to Finding a Soul Mate, What Our Lists Reveal About Us). The book includes creative list-making exercises with the aim of helping individuals to “get in touch with their passion for life, inside and out of work, and refocus them on what brings them alive”. Cagen now makes a living on writing and giving workshops on the benefits of list making (one of her major clients being Google)
Although the term ‘glazomania’ is seldom used academically or clinically, obsessive list making is often mentioned as one of the symptoms of obsessive-compulsive disorder. As one online admission I came across noted:
“I have OCD, and recently my OCD flares up in the form of compulsive list making. This behavior totally affects my ability to be productive because I am constantly afraid of forgetting something and of spending time doing the wrong thing. Does anyone have any tips on how to break the cycle?”
The Wikipedia entry on obsessive-compulsive personality disorder notes that the main symptoms are “preoccupation with remembering and paying attention to minute details and facts, following rules and regulations, compulsion to make lists and schedules, as well as rigidity/inflexibility of beliefs or showing perfectionism that interferes with task-completion. Symptoms may cause extreme distress and interfere with a person’s occupational and social functioning” (my emphasis)
Psychologically, an argument could be made that obsessive list makers are simply trying to create an illusion of control in otherwise chaotic lives. The reason whyindividuals with OCD make lists compulsively is that they often afraid (in some cases, to the point of being phobic) that they will forget something important (even though research shows they do not have memory problems). These (arguably unnecessary) lists provide a reminder to carry out daily activities (i.e. brushing teeth, making breakfast, etc.). As with other OCD-type behaviours, the action of making a list helps the individual to feel psychologically better (albeit temporarily). The etiological roots may lie in the fact that the sufferer may at some point in their past history have been reprimanded severely, or repeatedly, by others for innocently forgetting things that were important. The OCD Types website adds:
“They never learn that they do not need the list to remember things. People with OCD may also make lists to remember things that may be contaminated to later wash or avoid, which also contributes to the OCD process. List-making can be in writing or verbalized aloud”.
In 2010, the BBC reported an exhibition at the Archives of American Art in Washington featuring lists made by eminent artists (everything from “scribbled on scraps of paper” to the “elaborately illustrated” including lists by Pablo Picasso, Alfred Konrad, Oscar Bluemner, Eerp Saarinen and Harry Bertoia). Bluemner even kept lists of lists. The curator of the exhibition (Liza Kirwin) told the BBC that:
“In trying to give order to his life, [Bluemner] obscures the clarity of the inventory of his work. He’s completely obsessed with this type of record keeping…This very mundane and ubiquitous form of documentation can tell you a great deal about somebody’s personal biography, where they’ve been and where they’re going. People can relate to this form of documentation because so many people are list keepers and organise their lives this way”.
In the same article, the BBC interviewed the US psychoanalyst Dr. Michael Maccoby who claimed that there are various types of list makers. However, there was little detail and the only quote in relation to types of list makers claimed: “The extreme is the obsessive who has to make lists of everything. These are people who have an unconscious fear that everything is going to be out of control if they don’t make a list”. As far as I am aware, there is no published empirical research on personality types and list making although there is some psychological literature showing that list making – as part of time management practices – appears to have some beneficial effects on both student grade point averages and workplace productivity.
Finally, a few months ago, an online article by Dr. Carrie Barron at the Psychology Today website provided a brief summary of why making lists is psychologically good for people. I’m not sure about the empirical basis of her claims but they seem to have reasonable face validity. I’ll leave you with her reasons (her verbatim list of “six great benefits”!). In summary, Barron believes that lists:
- “Provide a positive psychological process whereby questions and confusions can be worked through.
- Foster a capacity to select and prioritize. This is useful for an information-overload situation.
- Separate minutia from what matters, which is good for identity as well as achievement.
- Help determine the steps needed. That which resonates informs direction and plan.
- Combat avoidance. Taking abstract to concrete sets the stage for commitment and action. Especially if you add self-imposed deadlines.
- Organize and contain a sense of inner chaos, which can make your load feel more manageable”.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Barron, C. (2014). How making lists can quell anxiety and breed creativity. Psychology Today, March 9. Located at: http://www.psychologytoday.com/blog/the-creativity-cure/201403/how-making-lists-can-quell-anxiety-and-breed-creativity
Cagen, S. (2007). To-Do List: From Buying Milk to Finding a Soul Mate, What Our Lists Reveal About Us. Chicago: Touchstone.
Griffiths, M.D. (1995). Psycholo-lists. The Psychologist: Bulletin of the British Psychological Society, 8, 240.
Griffiths, M.D. (1996). More psycholo-lists. The Psychologist: Bulletin of the British Psychological Society, 9, 384.
Griffiths, M.D. (2006). Tips on…To do lists. British Medical Journal Careers, 332, 215.
Griffiths, M.D. (2008). Tips on…’To do’ lists. Psy-PAG Quarterly, 68, 27-28.
O’Brien, J. (2010). The art of list-making. BBC News, March 3. Located at: http://news.bbc.co.uk/1/hi/8537856.stm
OCD Types (2014). About obsessive-compulsive disorder. Located at: http://www.ocdtypes.com/unusual-compulsions.php
Staeheli, U. (2012). Listing the global: Dis/connectivity beyond representation? Distinktion: Scandinavian Journal of Social Theory, 13(3), 233-246.
Wikipedia (2014). Obsessive-compulsive personality disorder. Located at: http://en.wikipedia.org/wiki/Obsessive–compulsive_personality_disorder
Muscle Dysmorphia (MD) describes a condition characterised by a misconstrued body image in individuals interpret their body size as both small and weak even though they may look normal or even be highly muscular. Those experiencing the condition typically strive for maximum fat loss and maximum muscular build. MD can have potentially negative effects on thought processes including depressive states, suicidal thoughts, and in extreme cases, suicide attempts. These negative psychological states have also been linked with concurrent use of Appearance and Performance Enhancing Drugs (APED) including Anabolic Androgenic Steroids (AAS).
MD was originally categorised in 1993 by Dr. H.G. Pope and colleagues (in the journal Comprehensive Psychiatry) as Reverse Anorexia Nervosa, due to characteristic symptoms in relation to body size. It has been considered to be part of the spectrum of Body Dysmorphic Disorders (BDD) referring to a range of conditions that tap into issues surrounding body image and eating behaviours. Consequently, there is a lack of consensus amongst researchers whether MD is a form of BDD, Obsessive-Compulsive Disorder (OCD) or a type of eating disorder. Earlier this year, Andy Foster, Dr. Gillian Shorter and I published a paper in the Journal of Behavioral Addictions about the ‘Addiction to Body Image’ model, and arguing that MD could perhaps be conceptualized as an addiction.
Our ‘Addiction to Body Image’ (ABI) model attempts to provide an operational definition and to introduce a standard assessment across the research area. The ABI model uses my addiction components model (outlined is a previous blog) as the framework in which to define muscle dysmorphia as an addiction. For the purposes of our paper, body image was defined using Sarah Grogan’s definition (from her 2008 book Body image: Understanding body dissatisfaction in men, women, and children) who said it was a person’s “perceptions, thoughts and feelings about his or her body”. We argued that the addictive activity in MD is the maintaining of body image via a number of different activities such as bodybuilding, exercise, eating certain foods, taking specific drugs (e.g., anabolic steroids), shopping for certain foods, food supplements, and/or physical exercise accessories, etc.).
In the ABI model, the perception of the positive effects on the self-body image is accounted for as a critical aspect of the MD condition. The maintenance behaviours of those with ABI may include healthy changes to diet or increases in exercise. However, such behaviours can hide or mislead those with ABI away from the negative thought processes that are driving their addiction. It is in the cognitive dysfunction of MD where we believe there is a pathological issue, and why the field has encountered problems with the criteria for the condition. The attempt to explain MD in the same manner as other BDDs may not be adequate due to the cognitive dysfunction occurring in the context of the potentially positive physical effects via improvements in shape, tone, and/or health of the body.
We also argued that there is a difference in the cognitive dysfunction with a misconstrued self-body image compared to other BDDs. The cognitive dysfunction causes the individual with MD to have a misconstrued view of their own body image, and the person believes they are small and puny. This negative mindset has the potential to cause depression and other disorders, and may facilitate the addiction. Unlike other conceptualizations of MD in the BDD literature, we would argue that the agent of the addiction is the perceived body image that is maintained by engaging in secondary behaviours such as specific types of physical activity and food. The most important thing in the life of someone with MD is how their body looks (i.e., their body image). The behaviours that the person with MD engages in (such as excessive exercise or disordered eating) are merely the vehicles by which their addiction (i.e., their perceived body image) is maintained.
Based on empirical evidence to date, we proposed that Muscle Dysmorphia could be re-classed as an addiction due to the individual continuing to engage in maintenance behaviours that cause long-term psychological damage. More research is needed to explore the possibilities of MD as an addiction, and how this particular addiction is linked to substance use and/or other comorbid health conditions. Controversy about the conceptual measurement of the condition, has led to a number of different scales adapted from different criteria that may not fully measure the experience of MD.
However, a group of questions that might test the applicability of the ABI approach to measuring and conceptualising MD have not been asked. Questionnaires such as the Exercise Addiction Inventory and the Bergen Work Addiction Scale (two scales that I co-developed) could be adapted to fit MD characteristics. Adequate conceptualisation is key to explore the clinically relevant condition. This new ABI approach may also have implications for diagnostic systems around similar conditions such as other BDDs or eating disorders.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Additional input: Andy Foster and Dr. Gillian Shorter
Andreassen, C.S., Griffiths, M. D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.
Foster, A.C., Shorter, G.W.& Griffiths, M.D. (2014). Muscle Dysmorphia: Could it be classified as an Addiction to Body Image? Journal of Behavioral Addictions, in press.
Griffiths, M.D. (1997). Exercise addiction: A case study. Addiction Research, 5, 161-168.
Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.
Griffiths, M. D., Szabo, A., & Terry, A. (2005). The Exercise Addiction Inventory: A quick and easy screening tool for health practitioners. British Journal of Sports Medicine, 39, 30-31.
Grogan, S. (2008). Body image: Understanding body dissatisfaction in men, women, and children. London: Routledge.
Mosley, P.E. (2009). Bigorexia: Bodybuilding and muscle dysmorphia. European Eating Disorders Review. 17, 191-198.
Murray, S. B., Rieger, E., Touyz, S. W., & De la Garza Garcia, Y. (2010). Muscle Dysmorphia and the DSM-V Conundrum: where does it belong? International Journal of Eating Disorders, 43, 483-491.
Nieuwoudt, J. E., Zhou, S., Coutts, R. A., & Booker, R. (2012). Muscle dysmorphia: Current research and potential classification as a disorder. Psychology of Sport and Exercise, 13, 569-577.
Olivardia, R. (2001). Mirror, mirror on the wall, who’s the largest of them all? The features and phenomenology of muscle dysmorphia. Harvard Review of Psychiatry, 9, 254–259.
Phillips, K. A. & Hollander, E. (1996). Body dysmorphic disorder.In T.A. Widige, A.J. Frances, H.A. Pincus, R. Ross, M.B. First, & W.W. Davis, Eds. DSM-IV Sourcebook, Volume 2. Washington DC: American Psychiatric Association.
Philips, K. A., Gunderson, C. G., Mallya, G., McElroy, S. L., & Carter, W. (1998). A comparison study of body dysmorphic disorder and obsessive-compulsive disorder. Journal of Clinical Psychiatry, 59, 568–575.
Pope, H. G., Jr., Gruber, A. J., Choi, P., Olivardia, R., & Phillips, K. A. (1997). Muscle dysmorphia. An underrecognised form of body dysmorphic disorder. Psychosomatics, 38, 548–557.
Pope, H. G., Jr., Katz, D. L., & Hudson, J. I. (1993). Anorexia nervosa and ‘‘reverse anorexia’’ among 108 male bodybuilders. Comprehensive Psychiatry, 34, 406–409.
Pope, C. G., Pope, H. G., Menard, W., Fay, C., Olivardia, R., & Phillips, K.A. (2005). Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body image, 2, 395-400.
Veale, D. (2004) Body dysmorphic disorder. Postgraduate Medical Journal. 80, 67-71.
In a previous blog on five ‘weird addictions’ I briefly mentioned pagophagia, a craving and compulsion for chewing ice. Pagophagia is a type of pica (which I also covered in a previous blog). Pica is defined as the persistent eating of non-nutritive substances for a period of at least one month, without an association with an aversion to food. Although the incidence of pagophagia appears to have increased over the last 30 years in westernized cultures, Dr. B. Parry-Jones (in a 1992 issue of Psychological Medicine) carried out some historical research and pointed out that both Hippocrates and Aristotle wrote about the dangers of excessive intake of iced water. Parry-Jones also noted that references to disordered eating of ice and snow were also recorded in medical textbooks from the sixteenth century. However, the first contemporary reference to pagophagia appears to have been a 1969 paper by Dr. Charles Coltman in the Journal of the American Medical Association entitled ‘Pagophagia and iron lack’.
Pagophagia is closely associated with iron deficiency anemia but can also be caused by other factors (biochemical, developmental, psychological, and/or cultural disorders). If pagophagia is due to iron deficiency (such as case studies of those with sickle cell anemia), it may sometimes be accompanied by fatigue (e.g., being tired even when performing normally easy tasks). Dr. Youssef Osman and his colleagues published a number of case reports of pagophagia in a 2005 issue of the journal Pediatric Haematology and Oncology including the case of a child with sickle cell anemia and rectal polyps (that caused a lot of bleeding and made the anemia worse):
“An 8-year-old Omani boy, a known case of sickle cell anemia…presented with history of craving for ice. The child was noticed over the last 4 months to like drinking very cold water and to open the deep freezer and scratch the ice and eat it. The parents tried to stop him from doing so, but they failed…The child was started on oral iron therapy…and his craving for ice was completely stopped. Meanwhile, the rectal polyp was removed surgically”.
Other potential health side effects include constant headaches (a ‘brain freeze’ similar to ‘ice cream headache’) and teeth damage although this is thought to be relatively rare. However, a recent paper by Dr. Yasir Khan and Dr. Glen Tisman in the Journal of Medical Case Reports highlighted the case of a 62-year-old Caucasian man who presented with bleeding from colonic polyps associated with drinking partially frozen bottled water.
Khan and Tisman also suggested that some people who are deficient in iron experience tongue pain and glossal inflammation (glossitis). Others claim that chewing ice may help those with stomatitis (i.e., inflammation of the mucous lining inside the mouth). A recent 2009 case study published by Dr. Tsuyoshi Hata and his colleagues in the Kawasaki Medical Journal, reported the case of a 37-year old Japanese women who ate copious amounts of ice to relieve the pain of temporomandibular joint disorder (i.e., chronic pain in the joint that connects the jaw to the skull). Khan and Tisman also claim that the classical symptoms of pagophagia have changed in the last 40 years since Dr. Coltman’s initial paper in the Journal of the American Medical Association.
“This may probably be the result of advances in technology and changes in culture. When initially described [by Coltman], pagophagia was defined as the excessive ingestion of ice cubes from ice trays and the ingestion of ice scraped from the wall of the freezer. With the advent of ice cube makers and auto defrosters, the presentation of pagophagia has changed in a subtle manner as described in…our patients. Now we observe a subtler ingestion and/or sucking of ice cubes from large super-sized McDonald’s-like cups and from the use of popular bottled water containers that have been frozen”.
There have been few epidemiological studies examining the prevalence of pagophagia. Such estimates vary widely within particular populations but (according to Dr. Youssef Osman and his colleagues) have been shown to be more common in low socioeconomic and underdeveloped areas. Pagophagia is thought to be relatively harmless in itself or to one’s health, although there are some claims in the literature that pagophagia can be addictive. However, empirical reviews suggest that pagophagia (and pica more generally) is part of the obsessive-compulsive disorder spectrum of diseases. As a consequence, some case studies even suggest that ice chewing compromises their ability to maintain jobs or personal relationships.
Treatment for pagophagia can often be overcome with iron therapy and Vitamin C supplements (to supplement iron deficiency if that is the cause). For instance, Dr. Mark Marinella in a 2008 issue of the Mayo Clinic Proceedings successfully treated a 33-year old woman with pagophagia following complications with gastric bypass surgery:
“The patient received red blood cells, iron sucrose, and levofloxacin. On further questioning, the patient denied taking vitamin, mineral, or iron supplements since surgery and reported prolonged, heavy menstrual cycles. She consumed large amounts of ice daily for several months. The patient’s husband frequently observed her in the middle of the night with her head in the freezer eating the frost off the icemaker. The patient admitted to awakening several times nightly for months with an uncontrollable compulsion to eat the frost on the icemaker. This craving resolved after transfusion and iron administration”
However, if the condition is psychologically or culturally based, iron and vitamin supplements are unlikely to work, and other psychological treatments (such as cognitive-behavioural therapy) are likely to be employed.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Coltman, C.A. (1969). Pagophagia and iron lack. Journal of the American Medical Association, 207, 513-516.
de Los Angeles, L., de Tournemire, R. & Alvin, P. (2005). Pagophagia: pica caused by iron deficiency in an adolescent. Archives of Pediatrics, 12, 215-217.
Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemadej, U.J., Cole, O.J., Westney, O.E., Jones, S. Laryea, H. & Westney, L.S. (1994). Pica in an urban environment. Journal of Nutrition (Supplement), 124, 954-962.
Hata, T., Mandai, T., Ishida, K., Ito, S., Deguchi, H. & Hosoda, M. (2009). A rapid recovery from pagophagia following treatment for iron deficiency anemia and TMJ disorder accompanied by masked depression. Kawasaki Medical Journal, 35, 329-332.
Khan, Y. & Tisman, G. (2010). Pica in iron deficiency: A case series. Journal of Medical Case Reports, 4, 86. Located: http://www.jmedicalcasereports.com/content/4/1/86
Kirchner, J.T (2001). Management of pica: A medical enigma. American Family Physician, 63, 1177-1178.
Marinella, M. (2008). Nocturnal pagophagia complicating gastric bypass. Mayo Clinic Proceedings, 83, 961
Osman, Y.M., Wali, Y.A. & Osman, O.M. (2005). craving for ice and iron-deficiency anemia: a case series. Pediatric Hematology and Oncology, 22, 127-131.
Parry-Jones, B. (1992). Pagophagia, or compulsive ice consumption: A historical perspective. Psychological Medicine, 22, 561-571.
In a number of previous blogs I have made reference to the fact that I am a music obsessive. One of the consequences of my insatiable desire for music is that I often find myself unconsciously singing (either along with the music itself or just spontaneously as the mood takes me). Although I do not believe I have a compulsion to break into song, I was surprised to find that there are a number of case studies in the psychological literature on compulsive singing and other music related compulsions such as compulsive humming and whistling (although these all appear to be consequences of other underlying conditions). As noted in a previous blog, compulsive behaviour typically involves a repetitive and irresistible urge to perform a particular action (or set of actions) where the person feels they have no control to inhibit or stop the habitual behaviour. Compulsivity is part of obsessive-compulsive disorder (OCD), but may occasionally occur as stand-alone symptom following the onset of various physiological disorders.
One of the earliest papers I came across on the phenomenon was by Dr. Daniel Jacome in a 1984 issue of the Journal of Neurology, Neurosurgery and Psychiatry. Dr. Jacome described the case of a “musically naive patient with dominant fronto-temporal and anterior parietal infarct developed transcortical mixed aphasia. From early convalescence, he exhibited elated mood with hyperprosody and repetitive, spontaneous whistling and whistling in response to questions”. In addition to the whistling, Jacome also reported that the individual spontaneously sang without any error in melody, lyrics, pitch, and rhythm. The man also developed the desire to spend long periods of time listening to music.
Compulsive whistling was also reported in a 2012 issue of BMC Psychiatry by Dr. Rosaura Polak and her colleagues. Their paper reported the case of a 65-year-old man who started whistling compulsively following a heart attack. The heart attack had caused some brain damage due to a lack of oxygen to the brain. Prior to the cardiac arrest, the man had never displayed any obsessive-compulsive symptoms or psychiatric complaints. He was treated with clomipramine (a seretonin reuptake inhibitor) and this decreased time spent compulsively whistling. The authors concluded that:
“This case shows that the whistling can be explained in the context of compulsivity with its repetitive character. It illustrates that the compulsive behavior can be present as an independent symptom of cortico-striatal dysfunction, and may not always belong to frontal syndrome, punding or OCD. Finally, this case illustrates that pharmacological treatment with clomipramine is effective and suggests that similar cases of compulsivity may benefit from this treatment”
A paper published in a 2000 issue of the Journal of the Korean Neurological Association examining 25 patients with fronto-temporal dementia (20 women and five men with an average age of 56 years) noted that compulsive behaviour is one of the commonest early manifestations of the condition. The researchers analyzed their symptoms and compulsive behaviours and 22 of the patients (88%) showed various compulsive behaviours including “reading signboards, stereotypy of speech, ordering, hoarding, washing, checking, counting, singing, and wandering a fixed route”. However, no real detail was provided in relation to the compulsive singing. Other papers – such as one in a 2002 issue of European Psychiatry by Dr. F. Muratori and colleagues – have reported compulsive singing in people that have Kleine-Levin syndrome (i.e., recurrent primary hypersomnia where individualscan lapse into a deep sleep at any time without warning, sometimes lasting as long as 16 hours).
One of the most interesting and detailed papers on compulsive singing is a 2007 paper by Dr. Christophe Bonvin and colleagues in the Annals of Neurology. They reported two case studies of individuals with advanced Parkinson’s disease who exhibited “a peculiar and stereotyped behavior characterized by an irrepressible need to sing compulsively when under high-dose dopamine replacement therapy”. They argued that the compulsive singing behaviour shared many features with punding (i.e., repetitive behaviour that is a side effect of some drugs). Here is a brief summary of the two cases:
Patient 1: “A 70-year-old female university professor and amateur piano player while being treated with 1,268 L-dopa equivalent units (LEU)…exhibited a repetitive, compulsive behavior characterized by singing endlessly…It started with an irrepressible urge to hum the rhythm and then the main melody of Francesca di Foix, a jocular opera written in 1831 by Gaetano Donizetti. She had heard this rarely produced piece in Milan years ago, and although she did not particularly like it, she had an obsessive need to repeat this song again and again for hours. Even though it was disruptive, preventing sleep and social interactions, singing was reported as pleasant and associated with a feeling of calmness and relief. If interrupted, she became irritated…All symptoms improved minimally after quetiapine (25mg twice daily) had been introduced”.
Patient 2: “A 71-year-old male painter…[that] grew up in a family of musicians and used to spend time listening to classical music and singing willingly…While being treated with 634 LEU, he started to hum repeatedly the same melody, initially once a week, then several times daily, mostly in the evening…Although he asserted singing exclusively Mozart’s 7th Serenade (‘Haffner’ KV 250), his wife reported also about 10 different poorly elaborated songs. This stereotyped behavior was reported as irrepressible and gave him a sensation of relief and ‘peace of mind’. On demand, he could stop singing for short periods but felt somewhat frustrated, demonstrating some aggressive behavior toward his spouse. There were no concomitant auditory or visual hallucinations. This phenomenon exacerbated dramatically when LD/benserazide was increased to 1,000/250mg daily (1134 LEU)…[This resulted in] the patient losing control over the compulsion and singing almost unendingly all day…Eventually, compulsive singing improved, but did not disappear, when LD/benserazide was reduced to the minimal daily doses (500/125mg)”.
The authors noted that in both of these patients developed a peculiar, stereotyped, and compulsive behaviour characterized by an urge to sing repeatedly the same song. They also concluded that in both cases:
“[The] compulsive singing developed as an isolated, elaborate, and selective feature, unrelated to mania or psychosis…Although the singing behavior was fully recognized by both patients as inadequate and socially disruptive, they were unable to stop singing for more than a few seconds to minutes, partly because the singing-induced sensation of pleasure felt was overwhelming. To the best of our knowledge, this phenomenon has not been consistently identified in [Parkinson’s disease] thus far…Moreover, PET and functional magnetic resonance imaging studies conducted in humans have correlated pleasure and reward from music listening with a significant activation of the ventral tegmental area and accumbens nucleus, as well as of the hypothalamus, insula, and orbitofrontal cortex. These findings suggest that music listening may recruit similar neural circuitry of reward and emotions as other pleasure inducing stimuli like food and sex, and this may also be the case for singing”.
In 2010, Dr. Hiroshi Kataoka and Dr. Satoshi Ueno described the case of an 82-year old woman (also with Parkinson disease) who started to sing compulsively (in the absence of any other types of pathologic behaviour) following treatment with pergolide. In the journal Cognitive and Behavioral Neurology, the authors reported that she would hum the same melody and sing songs repeatedly. When she stopped taking her ergolide medication, the compulsive singing and humming considerably subsided. Drs. Kataoka and Ueno suggested that a dopamine agonist in the patient’s medication may have contributed to her compulsive singing. The same phenomenon was also reported in three Parkinson’s patients treated with dopamine agonists by a Dr. C. Borrue-Fernandez at a Spanish conference on treating Parkinson’s disease in 2011.
It would appear from the few papers that have been published on compulsive singing that it almost always occurs alongside or as a consequence of other primary medical conditions and that some excessive or sensitized dopaminergic stimulation is a necessary prerequisite for such musical stereotypies to occur.
Bonvin, C., Horvath, J., Christe, B., Landis, T., & Burkhard, P. R. (2007). Compulsive singing: another aspect of punding in Parkinson’s disease. Annals of Neurology, 62, 525-528.
Borrue-Fernandez, C. (2011). Compulsive singing as an Impulse Control Disorder in dopamine agonist treated patients: Review of three cases. The 15th Congress of the European Federation of Neurological Societies.
Jacome, D. E. (1984). Aphasia with elation, hypermusia, musicophilia and compulsive whistling. Journal of Neurology, Neurosurgery and Psychiatry, 47, 308-310.
Kataoka, H., & Ueno, S. (2010). Compulsive singing associated with a dopamine agonist in Parkinson disease. Cognitive and Behavioral Neurology, 23(2), 140-141.
Muratori, F., Bertini, N., & Masi, G. (2002). Efficacy of lithium treatment in Kleine–Levin syndrome. European Psychiatry, 17, 232–3.
Polak, A. R., van der Paardt, J. W., Figee, M., Vulink, N., de Koning, P., Olff, M., & Denys, D. (2012). Compulsive carnival song whistling following cardiac arrest: a case study. BMC Psychiatry, 12(1), 75.
Yoon, S. J., Jeong, J. H., Kang, S. J., & Na, D. L. (2000). Compulsive behaviors and presenting symptoms of frontotemporal dementia. Journal of the Korean Neurological Association, 18, 681-686
I recently published a potentially controversial paper in the journal Frontiers in Psychiatry arguing that loss of control may not always be a natural consequence of addiction. Research into addiction has a long history although there has always been much debate as to what the key components of addiction are. Irrespective of the theory and model of addiction, most theorizing on addiction tends to assume (implicitly or explicitly) that ‘loss of control’ is central (if not fundamental) to addiction. My paper challenges such notions by arguing that there are a minority of individuals who appear to be addicted to a behaviour (i.e., work) but do not necessarily appear to display any loss of control.
Research into many different types of addiction has shown that addicts are not a homogeneous group, and this may also have implications surrounding control and loss of control. Many years ago, in my 1995 book Adolescent Gambling, I argued that in relation to problem gambling there appear to be at least two sub-types of addiction – primary addictions and secondary addictions. I defined primary addictions as those in which a person is addicted to the activity itself, and that individuals love engaging in the activity whether it is gambling, sex or playing video games. Here, the behaviour is primarily engaged in to get aroused, excited, and/or to get a ‘buzz’ or ‘high’. I defined secondary addictions as those in which the person engages in the behaviour as a way of dealing with other underlying problems (i.e., the addiction is symptomatic of other underlying problems). Here the behaviour is primarily engaged in to escape, to numb, to de-stress, and/or to relax.
Therapeutically, I argued that it is easier to treat secondary addictions. My argument was that if the underlying problem is addressed (e.g., depression), the addictive behaviour should diminish and/or disappear. Primary addicts appear to be more resistant to treatment because they genuinely love the behaviour (even though it may be causing major problems in their life). Furthermore, the very existence of primary addictions challenges the idea that loss of control is fundamental to definitions and concepts of addiction. Clearly, people with primary addictions have almost no desire to stop or cut down their behaviour of choice because it is something they believe is life affirming and central to the identity of who they are. But does lack of a desire to stop the behaviour they love prevent ‘loss of control’ from occurring? Arguably it does, particularly when examining the research on workaholism.
I have popularized the ‘addiction components model’, particularly in relation to behavioural addiction (i.e., non-chemical addictions that do not involve the ingestion of a psychoactive substance). The addiction components model operationally defines addictive activity as any behaviour that features what I believe are the six core components of addiction (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict and relapse, and which I outlined in my very first blog on this site)
One of the observations that can be made by examining these six criteria is that ‘loss of control’ is not one of the necessary components for an individual to be defined as addicted to an activity. Although I acknowledge that ‘loss of control’ can occur in many (if not most) addicts, loss of control is subsumed within the ‘conflict’ component rather than a core component in and of itself. The main reason for this is because I believe that there are some addictions – particularly behavioural addictions such as workaholism – where the person may be addicted without necessarily losing control. However, such a claim depends on how ‘loss of control’ is defined and the highlights the ambiguity in our standard understanding of addiction (i.e., the ambiguity of control as ability/means versus control as goal/end).
When theorists define and conceptualise ‘loss of control’ as applied to addictive behaviour, it typically refers to (i) the loss of the ability to regulate and control the behaviour, (ii) the loss of ability to choose between a range of behavioural options, and/or (iii) the lack of resistance to prevent engagement in the behaviour. In some behaviours such as workaholism and anorexia, the person arguably tries to achieve control in some way (i.e., over their work in the case of a workaholic, or over food in the case of an anorexic). However, this in itself is not a counter-example to the idea that addiction is a ‘loss of control’ if workaholics and anorexics have lost the ability to control other aspects of their day-to-day lives in their pursuit of control over work or food (i.e., there is a difference between control as the goal/end of behaviour, and control as an ability/means.
There is an abundance of research indicating that one of the key indicators of workaholism (alongside such behaviours as high performance standards, long working hours, working outside of work hours, and personal identification with the job) is that of control of work activities. In a recent paper I wrote with my colleague Dr. Maria Karanika-Murray in the Journal of Behavioral Addictions, we also noted that the need for control is high among workaholics, and as a consequence they have difficulty in disengaging from work leading to many other negative detrimental effects on their life such as relationship breakdowns. Even some of the instruments developed to assess workaholism utilize questions concerning the need to be in control.
There are also other studies that suggest some workaholics do not experience a ‘loss of control’ in the traditional sense that is used elsewhere in the addiction literature. For instance, in a 2004 issue of the Journal of Organizational Change Management, Dr. Peter Mudrack reported that two particular aspects of obsessive-compulsive personality (i.e., being stubborn and highly responsible) were predictive of workaholism. A very recent paper by Dr. Ayesha Tabassum and Dr. Tasnuva Rahman in the International Journal of Research Studies in Psychology noted that perfectionist workaholics experience an overbearing need for control and are very scrupulous and detail-oriented about their work. Unusually among addictions, workaholics usually have no desire to reduce or regulate their work behaviour (i.e., there is no ambivalence or conflicting desire for them). In this instance, there is no evidence of ‘loss of control’ as traditionally understood, because if they had ambivalent or conflicting desires, they would change their behaviour (i.e., reduce the amount of time they spend working). Although not an exhaustive list of studies, those mentioned here appear to indicate that some workaholics appear to be more in control than not in control.
When the addiction is primary, the goal/end of the behaviour is desired and/or endorsed without ambivalence by the addict. In these situations (as in some cases of workaholism), there is no evidence for loss of control, because no (failed) attempts are made by the addict to alter their behaviour. However, this could arguably still be compatible with the claim that there is loss of control in the sense of ability and/or means, because, if the workaholic tried to work less (or work in a less controlling way) because they started to recognize ill effects the addictive behaviour was having on their personal life, then they may fail to do so. Therefore, the lack of evidence is indicative rather than conclusive.
However, one of the reasons that workaholism raises interesting theoretical and conceptual issues concerning the loss of control is that it is an example of an addiction where the goal/end is itself a form of control (i.e., control over their productivity/outputs, control over others, control over time-keeping, etc.). Unlike many other addictions, such behaviour is not impulsive and/or chaotic but carefully planned and executed. So this raises the question, in what sense is workaholism a loss of control, understood in the typical way, as ability/means to the behaviour’s goal/end? In some cases of workaholism, there is no evidence that the workaholic lacks control over this goal/end, as they do not try to change their behaviour (and thus cannot fail to do so).
It could be argued – and this is admittedly speculative – that ‘loss of control’ as is traditionally understood appears to have a greater association with secondary addiction (i.e., where an individual’s addiction is symptomatic of other underlying problems) than primary (or ‘happy’ or ‘positive’) addiction (i.e., where an individual feels totally rewarded by the activity despite the negative consequences). Such a speculation has good face validity but needs empirical testing. However, a complicating factor is the fact that my studies on adolescent gambling addicts have demonstrated that some individuals start out as primary addicts but became secondary addicts over time. Again, this suggests that control (and loss of it) may be something that changes its nature over time.
In essence, workaholics appear to make poor choices and/or decisions that have wide-reaching detrimental consequences in their lives. However, at present we lack evidence that (should they decide otherwise) they would be unable to work in a more healthy way. Furthermore, and equally as important, the nature of workaholic behaviour is not impulsive and chaotic, but carefully planned and executed. This is particularly striking among some workaholics, because as I have noted, it is an addiction that for some individuals they continue to work happily despite objectively negative consequences (e.g., relationship breakdowns, neglect of parental duties, etc.). What the empirical research on workaholism suggests is that it is an example of an addiction in which the problem is better characterized as loss of prudence rather than loss of control, as traditionally understood.
Andreassen, C.S., Griffiths, M.D., Hetland, J. & Pallesen, S. (2012). Development of a Work Addiction Scale. Scandinavian Journal of Psychology, 53, 265-272.
Andreassen, C. S., Torsheim, T., Brunborg, G. S., & Pallesen, S. (2012) Development of a Facebook addiction scale. Psychological Reports, 110, 501-517.
Griffiths, M.D. (1995). Adolescent Gambling. London: Routledge.
Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.
Griffiths, M.D. (2011). Workaholism: A 21st century addiction. The Psychologist: Bulletin of the British Psychological Society, 24, 740-744.
Griffiths, M.D. & Karanika-Murray, M. (2012). Contextualising over-engagement in work: Towards a more global understanding of workaholism as an addiction. Journal of Behavioral Addictions, 1(3), 87-95.
Mudrack, P.E. (2004). Job involvement, obsessive-compulsive personality traits, and workaholic behavioral tendencies. Journal of Organizational Change Management, 17, 490-508.
Mudrack, P.E. & Naughton, T.J. (2001) The assessment of workaholism as behavioral tendencies: Scale development and preliminary empirical testing. International Journal of Stress Management, 8, 93-111.
Tabassum, A. & Rahman, T. (2012). Gaining the insight of workaholism, its nature and its outcome: A literature review. International Journal of Research Studies in Psychology, 2, 81-92.
It was only a few months ago that I watched the 2006 film Bug for the very first time. Directed by William Friedkin, it tells the story of a mentally ill drifter called Peter Evans (with a great performance by Michael Shannon). Evans ends up having a sexual relationship with Agnes White, a bisexual alcoholic junkie (played surprisingly well by Ashley Judd). During the film, Peter confides in Agnes his belief that he has a colony of microscopic bugs infested one of his molar teeth (and then in one ‘memorable’ scene starts pulling his own teeth out). Evans’ paranoia becomes increasingly erratic and becomes a shared belief with White (who also comes to believe that they are both infested with microscopic bugs; this sharing of a delusional belief is known as a ‘folie à deux’ [French for ‘a madness shared by two people’, a shared psychosis] and would make a good blog topic). However, today’s blog focuses on imagined bug infestation (i.e., delusional parasitosis) that is known in psychological and psychiatric terms as Ekbom’s syndrome (named after the Swedish neurologist Karl Ekbom who first described the condition in a number of published papers in the late 1930s).
As you have probably gathered from my quick film synopsis above, Ekbom’s syndrome (ES) is a type of psychosis in which sufferers have a vehement delusional belief that they are infested with parasites that those affected describe as bugs or insects crawling around under their skin (when in reality they simply do not exist). I ought to add that the characters in Bug also appeared to be suffering from ‘delusory cleptoparasitosis’ (DC) another type of insect psychosis in which the sufferer thinks the place where they live is infested with parasites (rather than from within their body). As a consequence, both ES and DC sufferers are more likely to seek the help of skin specialists (e.g., dermatologists) and insect specialists (e.g., pest control, entomologists) than psychologists.
In essence, ES is a tactile hallucination and is also known as ‘formication’ (which is the word that describes the feeling of insects crawling and/or burrowing underneath the skin’s surface. Formication is also one form of parasthaesia (of which other examples include the ‘pins and needles’ tingling sensations that many people experience regularly). Parasthaesia includes any non-permanent skin sensation including tickling, pricking, tingling, numbness, and/or burning. ES sufferers will focus on any unusual body mark on their skin as ‘evidence’ that they have a parasitic infection. It is not uncommon for obsessive and/or compulsive checking of the body to occur. The prevalence of ES is unknown although Dr. J. Koo and Dr. C. Gambla reported in the journal Dermatologic Clinic that they see around 20 new cases per year in the large US referral clinic.
In some psychological circles, ES has been used synonymously with Wittmaack-Ekbom syndrome that is more associated with ‘restless leg syndrome’ (RLS; something that I myself have suffered from due to a chronic spinal condition that I have). When I get my bouts of RLS, it really does feel as though I have tiny insects moving about inside my right leg. The difference between ES and RLS is that RLS is a real physical condition that has bona fide physical basis whereas the basis for ES is an imaginary delusion. Clinical and medical research has shown that ES is associated with a number of comorbid conditions including affective psychosis, paranoid schizophrenia, organic brain disease, neurosis, and anankastic/paranoid personality disorder. It has also been reported in some people undergoing alcohol withdrawal, cocaine misuse, cerebrovascular disease, senile dementia, and thalamic brain lesions.
There can also be medical complications for ES sufferers. The fictional example of someone pulling their teeth out is not unknown although the gouging or digging out of the perceived parasites is more common. However, a paper by Dr. M. Nel and colleagues in the Journal of the South African Veterinary Association, most ES sufferers are able to function normally in all other aspects of their lives, in spite of their fixed parasitic delusions. They also noted that:
“The typical history often describes numerous attempts at eradicating the infestation. These could include taking medication, applying topical treatments, using pesticides, making use of exterminators, discarding clothing and possessions and even relocating…In a study of 94 patients (Ohtaki, 1991), most patients complained of itching and/or a tickling sensation. In order to rid themselves of the so-called parasites, patients often scratch, pick and wash frequently or use caustic agents on their skin, almost invariably leading to traumatic skin lesions”.
According to one meta-analytic study of 1,223 ES cases (published by Dr. W. Trabart in the journal Psychopathology), the occurrence of ES as a shared psychotic disorder is an uncommon phenomenon. He reported only about 5-15% of such cases were found. It was also reported that ES was more common amongst females (two-thirds female, one-third male), and is more prevalent in those over the age of 40 years. The symptoms had lasted three to four-and-a-half years. ES can be classified into three sub-types (primary; secondary-functional; and secondary-organic) based on the presenting symptoms:
- Primary ES refers to individuals that have the delusional parasitic infestation but no other comorbid conditions (i.e., other mental functioning is normal). Those where ES occurs by suggestion from another individual (e.g., the folie a deux case mentioned above) would be included in this ES sub-type. (It’s also worth noting that at least three studies have reported either the folie à deux or folie à trois among family members or loved ones including papers in the British Journal of Psychiatry and Dermatologica). Treatment is usually pharmacotherapy-based and utilizes drugs that are used in the treatment of other delusional-based syndromes (e.g., atypical antipsychotic drugs such as risperidone and olanzapine.
- Secondary-functional ES refers to individuals that have the delusional parasitic infestation and are associated with another psychiatric condition (e.g., clinical depression, schizophrenia).
- Secondary-organic ES refers to individuals that have the delusional parasitic infestation that is caused by another medical illness (e.g., cancer, diabetes, tubercolosis, hyperthyroidism, vitamin deficiency, cerebrovascular disease, neurological disorders). Other conditions can also facilitate ES including drug abuse (including stimulant psychosis), various allergies, and the menopause). Treating the primary disorder will often lead to a reduction or elimination of the ES symptoms.
The most recent review of the literature I came across was by Dr. Andrea Boggild and colleagues, and published in a 2010 issue of the International Journal of Infectious Diseases, they concluded that:
“In summary, [delusional parasitosis] is one of the more challenging entities that infectious diseases specialists will be enlisted to help treat. Unfortunately, optimal therapeutic regimens leading to sustained remission are lacking, and assurances on the part of the clinician do little to ameliorate patient suffering”.
Berrios GE (1985). Delusional parasitosis and physical disease. Comprehensive Psychiatry 26, 395-403.
Boggild, A.K., Nicks, B.A., Yen, L., Voorhis, W.V., McMullen, R., Buckner, F.S., & Liles, W.C. (2010). Delusional parasitosis: six-year experience with 23 consecutive cases at an academic medical center. International Journal of Infectious Diseases, 14, e317–e321.
Bourgeois, M.L., Duhamel, P. & Verdoux, H. (1992). Delusional parasitosis: Folie à deux and attempted murder of a family doctor. British Journal of Psychiatry, 161, 709-711.
Frances, A. & Munro, A. (1989). Treating a woman who believes she has bugs under her skin. Hospital and Community Psychiatry, 40, 1113–1114.
Freinhar, Jack P (1984). Delusions of parasitosis. Psychosomatics, 25, 47-53.
Gieler, U. & Knoll, M. (1990). Delusional parasitosis as ‘folie à trois’. Dermatologica, 181, 122-125.
Goddard J (1995). Analysis of 11 cases of delusions of parasitosis reported to the Mississippi Department of Health. Southern Medical Journal 88, 837-839.
Gould, W.M. & Gragg, T.M. (1976). Delusions of parasitosis. Archives of Dermatology 112, 1745–1748.
Grace, K.J. (1987). Delusory cleptoparasitosis: Delusions of arthropod infestation in the home. Pan-Pacific Entomologist, 63, 1-4.
Koblenzer, C.S. (1993). The clinical presentation, diagnosis and treatment of delusions of parasitosi: A dermatologic perspective. Bulletin of the Society of Vector Ecologists 18, 6-10.
Koo, J. & Gambla, C (1996). Delusions of parasitosis and other forms of monosymptomatic hypochondriacal psychosis. General discussion and case illustrations. Dermatologic Clinic, 14, 429-438.
Morris, M. (1991). Delusional manifestation. British Journal of Psychiatry, 159, 83-87.
Hinkle, N.C. (2000). Delusory parasitosis. American Entomologist 46, 17-25.
Ohtaki, N. (1991). Ninety four cases with delusions of parasitosis. Japanese Journal of Dermatology, 101, 439-446.
Rasmussen, J.E. & Voorhees, J.J. (1990). Psychosomatic dermatology. Archives of Dermatology, 126, 90-93.
Nel, M., Schoeman, J.P. & Lobetti, R.G. (2001). Delusions of parasitosis in clients presenting pets for veterinary care. Journal of the South African Veterinary Association, 72, 167-169.
Trabert, W. (1995). 100 years of delusional parasitosis. Meta-analysis of 1,223 case reports. Psychopathology, 28, 238-46
Webb, J.P. (1993). Case histories of individuals with delusions of parasitosis in southern California and a proposed protocol for initiating effective medical assistance. Bulletin of the Society of Vector Ecologists 18, 16-24.
In my previous blogs, I have looked separately at pregnancy delusions (i.e., women and men who think and claim they are pregnant but are not – including Couvade Syndrome) and culture bound syndromes (i.e., a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies). Since writing those blogs I unearthed a fascinating academic paper examining one of the strangest culture bound syndromes I have ever come across. While idly looking for some inspiration for a new blog, I happened (by chance) to come across a blog written in November 2011 by Jesse Bering on the Scientific American website which began with this opening paragraph.
“Are you suffering abdominal pain or discomfort, fatigue, nausea, flatulence, heartburn, and acid reflux? Have you been having difficulty urinating, or experiencing pain while doing so? Oh, and one other question – have you been spontaneously expelling microscopic bits of disintegrated dog fetuses through your urethra? If you answered “yes” to all of the above, then you may be suffering from “Puppy Pregnancy Syndrome”.
Bering’s report was based on a 2003 paper published in the International Journal of Social Psychiatry, entitled “Puppy pregnancy in humans: A culture-bound disorder in rural West Bengal, India”. The paper described a phenomenon that has only ever been reported in this one Indian area (near Kolkata) where both and women are convinced that it is possible to become pregnant and carrying a canine foetus if they are bitten by dogs – particularly if the dog is sexually aroused and because the dog’s saliva contains dog gametes. The phenomenon is a fairly recent one as there are few reports of ‘puppy pregnancy’ prior to 2000.
The paper, by Dr. Arabinda N. Chowdhury (Professor of the Institute of Psychiatry, Kolkata, India) and colleagues featured seven cases of people suffering from puppy pregnancy (six males and one female). The men claim to give birth to the puppies via their penis (in a similar excruciating fashion to the way that men have to pass kidney stones). At night, the female case claimed she could hear the puppies barking in her abdomen.
They also interviewed a further 42 adult villagers to see how prevalent the belief in puppy pregnancy was. They reported that three-quarters of the villagers interviewed believed with “definite certainty” that puppy pregnancy existed (73%), while only 9% had no belief in the phenomenon. In fact, it was reported that almost all the villagers could name someone whose unexplained death they believed was the direct consequence of a toxic puppy pregnancy (including those who were among the most well educated). The authors noted that in relation to the cases they outlined that:
“Psychiatric status showed that there was a clear association of obsessive-compulsive disorder in two cases, anxiety-phobic locus in one and three showed no other mental symptom except this solitary false belief and preoccupation about the puppy pregnancy…One case (11-year-old child) exemplified how the social imposition of this cultural belief made him a case that allegedly vomited out an embryo of a dog foetus… the cases presented a mix of somatic and psychological complaints and their help-seeking behaviour was marked”.
Due to the widespread belief in the existence of puppy pregnancy fact, the village community has their own “medical” specialists who “treat” the condition called bara ojhas. These so-called specialists provide remedies and/or perform abortion-inducing rituals. During the early stages of “pregnancy”, the use of herbal medicines by bara ojhas are said to help dissolve the puppy foetuses so that they are naturally expelled through the person’s genitals in an unobtrusive way. In Jesse Bering’s account of puppy pregnancy, he describes the case of a male:
“After one 24-year-old college graduate had an encounter with a stray dog that scratched him on the leg six months earlier, he became extremely wary of dogs because he was deathly afraid that one might knock him up. He was so preoccupied with dogs that even in the interview room he was apprehensive that a dog may come out from under the table. To address his unending circular ruminations about puppy pregnancy, his dog anxiety, and his obsessive-compulsive need to search for microscopic fetal canine parts in his urine, he was prescribed Clomipramine (an antidepressant) and Thioridazine (an antipsychotic). Importantly, he also underwent a month of behavioral reconditioning with a dog while being treated as an inpatient”.
Obviously, the condition may have no medical basis, but on a psychological level, the people in the Indian community experiencing a puppy pregnancy believe it is real. Dr. Chowdhury and colleagues believe that the crux of the condition is “the absence of any realistic consideration about the absurdity of asexual animal pregnancy and pregnancy in males (to the degree of delusional conviction).”
Dr. Chowdhury and colleagues believe that Puppy Pregnancy Syndrome meets the criteria for a genuine Culture-Bound Disorder because the mass delusional belief occurs as a consequence of “emotionally fuelled social transmission” only found in a very particular community (in this case, rural West Bengal), and that the disorder needs “proper cultural understanding for its effective management”.
Jesse Bering’s blog also made reference to another culture where giving birth to animals is a widely held belief. Bering cited the anthropologist E.E. Evans-Pritchard’s account of the Azande people in Africa who believe that some women can give birth to cats. I actually managed to get hold of Evans-Pritchard 1976 book Witchcraft, Oracles, and Magic among the Azande. The Azande believe that many animals are witches or dead witches inhabiting the animals. The most feared animal by the Azande are wildcats (called the adandara) that they believe have sex with female villagers. These women then allegedly give birth to kittens who are then said to breastfeed them like human children. The appendices in Evans-Pritchard’s book (based on his interviews with the Azande) reported:
“The male cats have sexual relations with women who give birth to kittens and suckle them like human infants. Everyone agrees that these cats exist and that it is fatal to see them…There are not many women who give birth to cats, only a few. An ordinary woman cannot bear cats but only a woman whose mother has borne cats can bear them after the manner of her mother”.
When interviewing Azande people, Evans-Pritchard said that his personal contacts included only two cases of people who had actually seen adandara. He then went on to note:
“Azande often refer to lesbian practices between women as adandara…This comparison is based upon the like inauspiciousness of both phenomena and on the fact that both are female actions which may cause the death of any man who witnesses them…Homosexual women are the sort who may well give birth to cats and be witches also. In giving birth to cats and in lesbianism the evil is associated with the sexual functions of women”.
Given that so little information was given in Evans-Pritchard’s book, I have no idea if the belief in adandara could be classed as a culture-bound syndrome, but there do seem to be similarities with Puppy Pregnancy Syndrome.
Bering, J. (2011). Puppy pregnancy syndrome: Men who think they are pregnant with dogs. Scientific American, November 15. Located at: http://blogs.scientificamerican.com/bering-in-mind/2011/11/15/puppy-pregnancy-syndrome-men-who-are-pregnant-with-dogs/
Chowdhury, A., Mukherjee, H., Ghosh, H.K. & Chowdhury, S. (2009). Puppy pregnancy in humans: A culture-bound disorder in rural West Bengal, India. International Journal of Social Psychiatry, 49, 35-42.
E.E. Evans-Pritchard (1976). Witchcraft, Oracles, and Magic among the Azande. Oxford: Clarendon Press.
Voice of America (2012). Bizarre medical myth persists in rural India.Located at: http://www.voanews.com/content/bizarre-medical-myth-persists-in-rural-india-143818636/179310.html
Anyone who knows me will tell you that I don’t mind a bit of ‘pop psychology’ every now and again (and have even wrote articles defending it – see ‘further reading’ section below). I’m also someone who believes that art not only imitates life, but life can sometimes imitate art. This has led me to write academic articles on films (such as The Gambler) to see what extent the film represents the reality of psychological conditions. I’m also someone who uses film clips as teaching aids as sometimes film or a two-minute film clip says more than any academic paper about a particular psychological concept. (For instance, I think the film 12 Angry Men probably says more about the psychology of minority influence than any paper I’ve read on the topic). All this preamble is by way of saying there’s not a lot of academic research in this blog, and is one of the few times I will just write about whatever is on my mind.
Anyway, I was travelling back from a work trip to South Korea recently and caught up with a lot of films that I had been meaning to watch for some time. I watched four particular films on one plane flight – Eastern Promises, (released in 2007), Tattoo (2002), Red Dragon (2002), and The Girl With The Dragon Tattoo (2011) – where (quite by coincidence) tattoos were a fundamental part of three of the four story lines (perhaps somewhat ironically, the plot of The Girl With The Dragon Tattoo has little to do with tattoos). Soon after after I got back from my South East Asia trip, Channel 4 then screened a television documentary called My Tattoo Addiction. This got me thinking about how tattoos have become part of the mainstream and how for some people it borders on the obsessive. In a previous blog I briefly looked at the sexually paraphilic side of tattoos when I wrote about stigmatophilia (i.e., individuals being sexually aroused by scarring but now seems to include those who are sexually aroused by tattoos and piercings). However, today’s blog takes a brief look at the non-sexually obsessive elements of tattoos.
In the film Eastern Promises (directed by one of my favourite directors David Cronenberg), the actor Viggo Mortensen plays the character Nikolai Luzhin who is the driver of a man who used to be of high standing in the Russian mafia. I’m not going to reveal any of the story line but all the tattoos in the film tell the life stories of incarcerated Russian criminals who typically have dozens of tattoos all over their bodies. Here, the constant adding of tattoos is part of the subculture and has a purpose that has nothing to do with style or fashion, and is more to do with life history and psychological identity.
To acclimatize to his role, Mortensen researched and studied Russian gangsters (called the ‘vory’) and their tattoos. More specifically, he worked with Dr Gilly McKenzie (a Russian Mafia/organized crime specialist who worked for the United Nations) and watched relevant documentaries like The Mark of Cain that contains an in-depth examination of Russian criminal tattoos. For instance, in researching this blog I have since learned that among Russian prisoners (i) an upwards-facing spider tattoo refers to an active criminal, (ii) a pair of eyes on the underside of the abdomen refers to the person being homosexual, and (iii) a skull inside a square (as a finger ring) refers to a robbery conviction. Mortensen’s tattoos were incredibly realistic (so much so that when making the film, he had dinner in a Russian restaurant in London and the other diners stopped talking out of fear!). Mortensen also admitted that:
“I talked to [real Russian gangsters] about what [the tattoos] meant and where they were on the body, what that said about where they’d been, what their specialties were, what their ethnic and geographical affiliations were. Basically their history, their calling card, is their body.”
Given the title of the film, it’s not surprising that the film Tattoo (directed by German film director Robert Schwentke) features tattoos as fundamental to the story plot. The main underlying story involves a serial killer who is obsessively murdering people for their tattoos (i.e., the body tattoos are viewed as a work of art by thekiller). The subject of killing people for their tattoos has been covered in other stories (most notably by Roald Dahl in his short story Skin) but the film is very good and unlike Eastern Promises where the seemingly obsessive motivation for the tattoos is a statement about life history and belonging to their cultural group (the vory), in this film the people who have all over body tattoos are a walking piece of art and the obsession is with the unseen protagonist.
I ought to mention there is another (1981) film called Tattoo (directed by Bob Brooks) that is about tattoo obsession. In this earlier film, Bruce Dern plays the character Karl Kinsky, a mentally unstable tattoo artist who makes his living by creating temporary tattoos for models. Kinsky becomes obsessed with a model (Maddy), kidnaps her, and forces her to wear ‘his mark’ (i.e., a full body tattoo). He keeps her captive as he creates his masterpiece on her body. The strapline on all the film posters says it all: “Every great love leaves its mark”.
In the film Red Dragon, (based on Thomas Harris’ novel of the same name), one of the film’s main characters (Francis Dolarhyde) has a huge tattoo of (surprise, surprise) a red dragon on his back because of his extreme obsession with William Blake’s painting The Great Red Dragon and what he feel it represents. The tattoo covered all of Dolarhyde’s back, and extended onto his upper arms and down onto his buttocks and legs (although this doesn’t win the prize for the most tattooed man in a film – that surely must be ‘Carl’ played by Rod Steiger in the 1969 film The Illustrated Man).
What I find fascinating about all these films is the different ways that psychological obsessions can manifest themselves, and how the stories involving tattoos are totally believable because tattoos have become so much part of Westernized culture over the last decade. Not only that but tattoos have become ‘normalized’ and call into question academic research into excessive tattooing. For instance, I recently read a 2002 case report by Dr. Harpreet Duggal on repetitive tattooing as an obsessive-compulsive disorder that talked about excessive tattoos being linked to those with an anti-social personality disorder and being a “self-mutilatory behaviour”. Their report (which was only written a decade ago):
“Tattooing has been viewed as an act of self-mutilation (Raspa & Cusack, 1990), the latter being a characteristic of borderline personality disorder. The noteworthy aspect of this case is that tattooing initially represented an act of self-mutilation in consonance with the underlying personality disorder. However, later it became repetitive and had a ‘compulsive’ quality to it, though not a true compulsion by definition. There are rare reports of self-mutilation taking on a compulsive pattern but this mostly occurs with cutting and burning acts”.
This leaves me wondering how heavily tattooed celebrities like David Beckham, Johnny Depp, Robbie Williams, and Angelina Jolie would feel if they read how their behaviour might be pathologized by psychologists and psychiatrists alike?
Duggal, H.S. & Fisher, B. (2002). Repetitive tattooing in borderline personality and obsessive- compulsive disorder. Indian Journal of Psychiatry, 44, 190–192.
Griffiths, M.D. (1995). ‘Pop’ psychology. The Psychologist: Bulletin of the British Psychological Society, 8, 455-457.
Griffiths, M.D. (1995). Pop psychology and “aca-media”: A reply to Mitchell. The Psychologist: Bulletin of the British Psychological Society, 8, 537-538.
Griffiths, M.D. (1996). Media literature as a teaching aid for psychology: Some comments. Psychology Teaching Review, 5(2), 90.
Griffiths, M. (2004). An empirical analysis of the film ‘The Gambler’. International Journal of Mental Health and Addiction, 1(2), 39-43.
Raspa, R.F. & Cusack, J. (1990) Psychiatric implications of tattoos. American Family Physician, 41,1481-1486.