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Making the cut: A beginner’s guide to Klingsor Syndrome

In one of my previous blogs, I looked at one of the world’s rarest behaviours – male genital self-mutilation (GSM). As I noted in that article, there have only been about 125 cases ever recorded in the clinical and/or medical literature. (Having said that, it may be that this number of cases relates to those published in the English language as I did come across a Japanese case study of male GSM by M. Tomita and colleagues published in 2002 in the Japanese journal Hinyokika Kiyo, that noted that their case study was the 24th case of male GSM in the Japanese scientific literature). A 1988 study by Dr. C. Tobias and colleagues published in the South Medical Journal reported that self-mutilators (including all types of self-mutilation not just GSM) were most likely to suffer from schizophrenia, religious preoccupation, substance abuse, and/or social isolation.

Today’s blog specifically looks at genital self-mutilators who engage in the behaviour because of a religious belief, and are typically diagnosed as having Klingsor Syndrome. The name of the syndrome was derived from the character Klingsor in Parsifol (a Wagner opera) who engaged in an act of self-castration to gain entry into the Brotherhood of the Knights of the Holy Grail.

In a 1990 issue of the Australian and New Zealand Journal of Psychiatry, Dr. I. Schweitzer wrote a paper called ‘Genital self-amputation and the Klingsor syndrome’. In his paper, he described two psychotic individuals, who had carried out GSM on themselves (one of which had done it in an attempt to kill himself). He noted that those most at risk from committing GSM were similar to self-mutilators more generally and comprised:

“Psychotic patients with delusions (often religious), sexual conflict associated with guilt, past suicide attempts or other self-destructive behaviour and depression, severe childhood deprivation, and major premorbid personality disorder”.

Dr. Schweitzer tried to argue that ‘Klingsor syndrome’ should be applied to anyone that carries out GSM as a result of psychotic illness and not just those with religious delusions. However, this does not appear to have been taken up that widely in more recent published case studies. A couple of (seemingly) genuine cases of the ‘archetypal’ Klingsor Syndrome, were reported in the Indian Journal of Psychiatry. The first one was by Malay Dave and colleagues in 1997, and described the case of a 22-year old unmarried schizophrenic Muslim male:

“[He] was admitted in the urology department with self-inflicted traumatic amputation of the penis At that time some Muslim men accosted him and told him not to be seen in that locality again. After this incident the patient became fearful, started hearing voices belonging to the devil and Allah which would tell him that he was not… At the initial interview the patient was uncommunicative and rapport was difficult to establish. He had a perplexed affect…As the patient gradually became more controlled delusions of persecution, reference and control were elicited along with thought insertion and broadcast. His concept formation was average and auditory hallucinations (2 voices belonging to the God and the devil talking amongst themselves and to him, saying derogatory things) were elicitable. These voices had initially commanded the patient to cut off his penis”.

The second one was published in 2001 by Dr. Subhash Bhargava and colleagues. They wrote that:

A 25-year old unmarried male presented to the emergency services as he had severed off his penis with a knife. Patient reported of feeling no pain at that time and explained this act as carrying out the orders given to him by the goddess. The voice had assured him that by doing so his sins would be expiated and that he would attain sainthood. His family reported that he had disturbed sleep, a decline in work performance, increased talking, mainly religious in content and disinhibited behaviour off and on for the past seven months…Mental status examination revealed bizarre sexual and religious delusions and auditory hallucinations. The latter were accusatory as well as commanding in nature and mainly religious in content. A diagnosis of schizophrenia was made”.

A 2010 paper in the Israel Journal of Psychiatry and Related Sciences by Turkish clinicians led by Dr. Erol Ozan outlined four cases of GSM (three schizophrenics, and one with psychotic bipolar depression) forwarded some other symptoms that appear to put men at risk of GSM including (i) failures in the male role, (ii) problems in the early developmental period, (iii) such as experiencing difficulties in male identification and persistence of incestuous desires, (iv) depression, and (v) having a history of GSM. They also proposed a new concept in formulating religiously themed psychotic male GSM – atonement.

Another more recent (2012) paper in the Israel Journal of Psychiatry and Related Sciences by Indian researchers Dr. Ranjan Bhattacharyya and colleagues described a case of male GSM who was a paranoid schizophrenic who castrated himself at a time when no psychotic symptoms were present (but were enacted during a period of what the authors described as “post-psychotic depression”). Following a review of the psychological literature on male GSM, they considered that their case “best [fitted] the description for Klingsor Syndrome” probably because their case study was of a man “recovering from a psychotic episode with possible sexual guilt, religiosity and intense hatred towards women”. The religiosity in this case didn’t seem to be as pronounced as the two cases published in the Indian Journal of Psychiatry (outlined above). Given the rarity of any kind of GSM, it would appear that Klingsor Syndrome is arguably one of the world’s rarest syndromes. Every new case study appears to add to our knowledge of this strange (and potentially life threatening) behaviour.

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

Further reading

Ajape, A.A., Issa, B.A., Buhari, O.I.N., Adeoye, P.O., Babata, A.L. & Abiola, O.O. (2010). Genital self-mutilation. Annals of African Medicine, 9, 31-34.

Bhargava, S.C., Sethi, S., & Vohra, A.K. (2001). Klingsor syndrome: a case report. Indian Journal of Psychiatry, 43, 349-350

Bhattacharyya, R., Sanyal, D. & Roy, K. (2011). A case of Klingsor Syndrome: when there is no longer psychosis. Israel Journal of Psychiatry and Related Sciences, 48, 30-33.

Dave, M., Apte, J., Dhavale, H.S. & Pinto, C. (1997). The Klingsor Syndrome. Indian Journal of Psychiatry, 39, 341-342.

Martin, T. & Gattaz, W.F. (1991). Psychiatric aspects of male genital mutilations. Psychopathology, 24, 170.

Murota-Kawano, A, Tosaka, A. & Ando, M. (2001). Autohemicastration in a man without schizophrenia. International Journal of Urology, 8, 257-259.

Ozan, E., Deveci, E., Oral, M., Yazici, E., & Kirpinar, I. (2010). Male genital self-mutilation as a psychotic solution. Israel Journal of Psychiatry and Related Sciences, 47, 297-303.

Rao, K.N., Bharathi, G., & Chate S. (2002). Genital self-mutilation in depression: A case report. Indian Journal of Psychiatry. 44, 297-300.

Russell, D.B., McGovern, G. & Harte, F.B. (2005). Genital self-mutilation by radio frequency in a male-to-female transsexual. Sexual Health, 2, 203-204.

Schweitzer, I. (1990). Genital self-amputation and the Klingsor syndrome. Australian and New Zealand Journal of Psychiatry, 24, 566-569.

Stunnell, H., Power, R.E., Floyd, M., & Quinlan, D.M. (2006). Genital self-mutilation. International Journal of Urology, 13, 1358-1360.

Tobias, C.R., Turns, D.M., Lippmann., S., Pary, R. & Oropilla, T.B. (1988) Evaluation and management of self-mutilation. South Medical Journal, 81(10), 1261-1263.

Tomita, M., Maeda, S., Kimura, T., Ikemoto, I. & Oishi, Y. (2002). [A case of complete self-mutilation of penis]. Hinyokika Kiyo, 48, 247-249.

Waugh, A.C. (1986). Autocastration and biblical delusions in schizophrenia. British Journal of Psychiatry, 149, 656-658.

Aural wrecks: A brief look at self-mutilation of the ear

If I was playing a word association game and said the words ‘self-inflicted ear mutilation’, I would hazard an educated guess that the first thing that popped into most people’s minds would be the Dutch artist Vincent Van Gogh. On the evening of December 23, 1888, in Aries (France) Van Gogh (in a state of deep depression) cut off the lower part his own right ear with a razor (and later immortalized in his famous painting Self Portrait With Bandaged Ear). Earlier in the day he had threatened his long-time friend and artist Paul Gaugin with a razor and was not in a good state of mind (both that day and in life more generally). Van Gogh had become a heavy smoker and heavy drinker and had taken a liking to the alcoholic drink absinthe. After cutting off his ear, he took it over to a local brothel and gave it to a prostitute called Rachel (telling her to take good care of it). He would have died of blood loss but the local police took him to the hospital.

This incident has given rise to what has been called the Van Gogh Syndrome which has now become a catch-all term for self-mutilation, particularly in relation to amputation of a bodily extremity (such as the cutting off of one’s own penis, or the removal of one’s own eye). Such actions may be due to a wide range of conditions including psychoses, mood disorders (e.g., clinical depression), body dysmorphic disorder, or as a component of Lesch-Nyhan syndrome (a genetic disorder that affects how the human body builds and breaks down purines).

Van Gogh would have been classed as a ‘psychotic self-mutilator’ in psychiatrist Karl Menninger’s self-mutilation typology developed in the 1930s. He proposed that self-mutilators fall into one of six categories:

  • Neurotic self-mutilators: These individuals comprise nail biters and pickers, extreme hair removal and those seeking unnecessary cosmetic surgery.
  • Religious self-mutilators: These individuals comprise self-flagellators and/or genital self-mutilators.
  • Puberty rite self-mutilators: These individuals comprise those who engage in hymen removal, circumcision or clitoral alteration.
  • Psychotic self-mutilators: These individuals engage in eye or ear removal, genital self-mutilation and extreme amputation.
  • Organic disease self-mutilators: These individuals comprise those who engage in repetitive head banging or hand biting, intentionally fracturing fingers and eye removal, due to diseases such as encephalitis or disorders such as severe mental retardation.
  • Conventional self-mutilators: These individuals comprise normal people that engage in customary or conventional forms of self-mutilation (that most would argue is not self-mutilation at all, e.g., nail clipping, hair trimming, and beard shaving).

More recent typologies tend to talk about self-harm rather than self-mutilation and class such behaviour into one of three types (i.e., psychotic, organic or typical). Again, Van Gogh would be classed as a psychotic self-harmer:

  • Psychotic self-harmers: These individuals comprise those who remove or amputate body parts (e.g., eyes, limbs, ears, genitals, digits). In these cases, body part removal is carried out in response to hallucinations bought on by psychosis. Unsurprisingly, this is the most severe type of self-harming.
  • Organic self-harmers: These individuals comprise those who self-harm in the form of behaviours such as head-banging and lip-biting because of conditions such as Autistic Spectrum Disorders, developmental disabilities, and other similar disorders. Here the self-harm is a consequence of physical or chemical issues in the body.
  • Typical self-harmers: These individuals comprise those who self-harm in the form of self-cutting, burning, hair-pulling (trichotillomania), skin-picking (dermotillomania), biting, hitting, interference with wound healing, scratching or bone-breaking. Here, the self-harm is initiated by emotional or psychological trauma that is unrelated to psychotic or organic conditions. This is the most common type of self-harming.

In a 2006 issue of the Journal of Deaf Studies and Deaf Education, Dr. David Veale reported that major self-injurious behaviours tend to “be very isolated events and consists of severe or life-threatening tissue damage, such as self-castration, eye nucleation, or less commonly self-amputation of a limb or ear. They mainly occur in young psychotic men or older males with psychotic depression usually in the context of command auditory hallucinations or delusions of guilt”.

Despite the fact that self-inflicted ear mutilation is well documented, there are surprisingly few published case studies. In 1989, Dr. J. Silver and colleagues published a case study of self-inflicted ear mutilation (as part of wider self-mutilation) in the journal Psychosomatics. Their case was a 35-year old male paranoid schizophrenic who presented for treatment following dermatological self-mutilation following severe lacerations (including the ear, arms, and face). They concluded that the self-mutilation behaviour appeared to be associated with his psychotic symptoms, and that the self-mutilation was exacerbated by failure to take his neuroleptic medication.

Dr. Christopher Alroe and Dr. Venkat Gunda reported some cases of self-inflicted ear mutilations in a 1995 issue of the Australian and New Zealand Journal of Psychiatry. They presented three cases of self-amputation of the ear by three white right-handed men. All three men had psychiatric problems (one having schizophrenia and two having personality disorders. They compared their cases with that of van Gogh. The authors also surveyed all Australian and New Zealand prisons to determine the frequency of self-mutilation of the ears within the last five years. They found only one other case. Based on the cases, they argued that connections exist between the self-amputees and supports the notion that self-mutilation is “contagious”.

It is also worth noting that there are cases of people who have cut off their ears but would not be classed as psychotic because they have done it for a very specific reason. The most recent case was that of British prisoner Michael O’Donnell who (on May 2, 2010) cut off his ear so that he could escape from an ambulance while he was being transported to hospital for treatment. In the end, it was all in vain as he was caught and re-arrested three weeks later.

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

Further reading

Alroe, C.J., & Gunda, V. (1995). Self-Amputation of the Ear: Three Men Amputate Four Ears within Five Months. Australian and New Zealand Journal of Psychiatry, 29, 508-512.

Edwards, G. (1998). A brief history of ear mutilation. Deluxe. Located at: http://rulefortytwo.com/articles-essays/gallimaufry/ear-mutilation/

Menninger, K. (1935). A psychoanalytic study of the significance of self-mutilation. Psychoanalytic Quarterly, 4, 408-466.

Menninger, K. (1938). Man Against Himself. New York: Jovanovich.

Silva, J.A., Leong, G.B. & Weinstock, R. (1989). A case of skin and ear self-mutilation. Psychosomatics, 30, 228-230.

Press Association (2010). Prisoner who cut off ear to escape is recaptured. The Guardian, May 28. Located at: http://www.guardian.co.uk/uk/2010/may/28/prisoner-cut-off-ear-recaptured

Veale, D. (2006). A compelling desire for deafness. Journal of Deaf Studies and Deaf Education, 11, 369-372.