Blog Archives

Stitches brew: A brief look at self-harm lip sewing

In previous blogs I have examined both self-harming behaviour (such as cutting off one’s own genitals, removing one’s own eye, removing one’s own ear, self-asphyxial risk taking in adolescence, and religious self-flagellation) and extreme body modification. One area where these two areas intersect is lip sewing. According to the Wikipedia entry on lip sewing:

“Lip sewing or mouth sewing, the operation of stitching together human lips, is a form of body modification. It may be carried out for aesthetic or religious reasons; as a play piercing practice; or as a form of protest. Sutures are often used to stitch the lips together, though sometimes piercings are made with needle blades or cannulas and monofilament is threaded through the holes. There is usually a fair amount of swelling, but permanent scarring is rare. Lip sewing may be done for aesthetic reasons, or to aid meditation by helping the mind to focus by removing the temptation to speak. BMEzine, an online magazine for body modification culture, published an article about a 23-year-old film student Inza, whose quest for body modifications was very varied. She spoke about her experiences with lip sewing as a form of play piercing”.

My reason for writing this blog was prompted by a case study published by Dr. Safak Taktak and his colleagues in the journal Health Care Current Reviews. (I ought to add that I have read a number of papers by Taktak and his colleagues as they have reported some interesting other interesting case studies including those on shoe fetishism, semen fetishism, and fetishes more generally – see ‘Further reading’ below). In this particular paper, they reported the case of a male prisoner who had continually sewed his lips together. Although they were aware of cases of sewing lips together as a form of protest, they claimed that there had never been any case reported in the medical literature.

lip-sewing

The case report involved a male 37-year old Turkish (imprisoned) farmer, father of two children, with only basic education. After sewing his lips together, the man was brought into the hospital by the police, along with a handwritten note that read: “My jinns imposed speech ban to me and they made me sew my lips unwillingly. Otherwise, they threaten me with my children. I want to meet a psychiatrist urgently”. (Jinns I later learned are – in Arabian and Muslim mythology – intelligent spirits of lower rank than the angels, able to appear in human and animal forms and are able to possess humans). Not only were his lips sown together with black thread but he had also sewn both of his ears to the side of his head (these are also photographed in the paper and you can download the report free from here). This was actually the fourth time the man had sewed his lips together (but the first that he had sewn his ears). Each time, the doctors took out the stitches and dressed the wounds. The authors examined previous documentation about the man and reported that the man had been in prison for four years after injuring someone (no details were provided) and had been diagnosed with both anxiety disorder and anti-social personality disorder. On a prison ward comprising ten other prisoners, he had attempted suicide when trying to hang himself (in fact, you can clearly see the marks on his neck in the paper’s photographs). The authors reported that:

[The man] had blunted affect. He wasn’t able to stay in the [prison] ward because of the directive voices in his head. He declared he needed to stay in the ward alone. He heard all the words as swearing and he was punished by some people as well as some entities. He also said that some jinns in the form of animals threatened him not to speak and listen to anyone; otherwise they were going to kill his kids. He wanted to protect his children [and] he stitched his lips not to speak anyone and stitched his ears not to hear anyone. In his family history, he stated that his uncle committed suicide by hanging himself and saying ‘the birds are calling me’; his father was schizophrenia-diagnosed”.

The authors then reported:

“The patient stated that he sewed his lips with any colour of thread he could find. He had approximately fifteen pinholes on his upper and lower lips. He tended to suicide with directive auditory and visual hallucination (sic) and reference paranoid delirium. As he was imprisoned, he wasn’t able to use drugs. The patient who was thought to have a psychotic disorder was injected [with] 10 mg haloperidol intramuscularly and he was sent to a safe psychiatry hospital”.

As I have noted in my previous blogs on self-harming behaviour (and as noted in this particular paper), there are many different definitions of what constitutes self-destructive behaviour. This particular case was said to be suited to the psychotic behaviours characterised by Dr. Armando Favazza’s three self-destructive behaviours (i.e., compulsive, typical, and psychotic) outlined in his 1992 paper ‘Repetitive self-mutilation’ (published in the journal Psychiatry Annals). In their discussion of the case, the authors noted:

“The cases like sewing one’s own lips which we observe as a different type of destructing oneself in our case are mostly regarded as intercultural expression of feelings. The ones, who sew their lips in order to protest something, show their reactions by blocking the nutrition intake organ to the ones who want to continue their superiority. It can be expected in psychotic cases that the patients or his beloved ones might be harmed, damaged or affected emotionally. Thus, the patient who is furious and anxious might react by [attempting] violence as a reaction to these repetitive threats. Auditory hallucinations giving orders can cause the aggressive behaviours to start…In our psychotic case, this kind of behaviour is a way to prevent the voices coming from his inner world, not to answer them and hence making passive defending to world which he does not want to interact. By this means, he may harmonise with the secret natural powers which affect him and he may protect himself his children…[also] there can be a relief through sewing lips and ears or strangulation against the oppression created by the person not being able to adapt the prison…It should not be forgotten that the prison is a stressful environment and stressful living [increases] the disposition to psychopathologic behaviour that the living difficulties in prisons can affect the way of thinking and the capacity of coping and it may cause different psychiatric incidences”.

As noted at the start of this article, lip sewing is typically attributed to religious reasons, reasons of protest or aesthetic reasons. In this particular case, none of these reasons was apparent (and therefore notable – in the medical and psychiatric literature at the very least). The addition of sewing his ears appears to be even more rare, and thus warrants further research.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Favazza, A.R. (1992). Repetitive self-mutilation. Psychiatric Annals, 22(2), 60-63.

Taktak, S., Ersoy, S., Ünsal, A., & Yetkiner, M. (2014). The man who sewed his mouth and ears: A case report. Health Care Current Reviews, 2(121), 2.

Taktak, S., Karakus, M., & Eke, S. M. (2015). The man whose fetish object is ejaculate: A case report. Journal of Psychiatry, 18(276), 2.

Taktak, S., Karakuş, M., Kaplan, A., & Eke, S. M. (2015). Shoe fetishism and kleptomania comorbidity: A case report. European Journal of Pharmaceutical and Medical Research, 2, 14-19.

Taktak, S., Yılmaz, E., Karamustafalıoglu, O., & Ünsal, A. (2016). Characteristics of paraphilics in Turkey: A retrospective study – 20years. International Journal of Law and Psychiatry, in press.

Wikipedia (2016). Lip sewing. Located at: https://en.wikipedia.org/wiki/Lip_sewing

Wholly holy: A beginner’s guide to Jerusalem syndrome

In a previous blog I examined Stendhal Syndrome where some people when exposed to the concentrated works of art, experience a wide range of symptoms including physical and emotional anxiety (rapid heart rate and intense dizziness, that often results in panic attacks and/or fainting), feelings of confusion and disorientation, nausea, dissociative episodes, temporary amnesia, paranoia, and – in extreme cases – hallucinations and temporary ‘madness’. While researching that article, I also came across another condition that would appear to be related to Stendhal Syndrome, namely ‘Jerusalem Syndrome’ – a condition that I have some empathy with.

One of the things I love about my job is all the wonderful places I have been able to travel to and visit as part of my work. Back in 2010, I did some consultancy on social responsibility practices for the online gambling company 888 and was flown to Tel Aviv to speak to various departments about my work. Once my talks and meeting were over, I experienced one of the best days of my life when I given a personal guide around the whole of Jerusalem. I am not religious but I found myself totally overcome with emotion as I visited one tourist attraction after another.

I say all this by way of introduction to what has been reported in the psychological literature as the aforementioned ‘Jerusalem Syndrome’ where visitors to the holy city are totally overcome by the weight of its history. The condition was first described (perhaps unsurprisingly) by an Israeli psychiatrist – Haim Herman – in the 1930s. However, psychiatrists did not begin keeping comprehensive clinical and statistical information on these cases until the late 1970s. One of the most infamous cases often cited in relation to Jerusalem Syndrome occurred in 1969, when a male Australian tourist (Denis Michael Rohan) set alight the al-Asqa Mosque following an overwhelming feeling of divine mission.

In 1999, Dr. Eliezer Witzum and Dr. Moshe Kalian wrote the first paper on Jerusalem Syndrome in an issue of the Israelian Journal of Psychiatry and Related Sciences. The condition became more widely known in 2000, when Dr. Yair Bar-El and colleagues published a paper in it in the British Journal of Psychiatry (BJP). Since 1980, Dr. Bar-El and his colleagues reported that Jerusalem’s psychiatric services had encountered over 1000 tourists with Jerusalem Syndrome (approximately 100 a year and overwhelmingly evangelical Christians). All cases were sent to one central facility (the Kfar Shaul Mental Health Centre [KSMHC]) for psychological counselling, psychiatric intervention, and/or admission to hospital. Between 1980 and 1993 approximately 1200 tourists with severe, Jerusalem-generated mental problems were referred to the KSMHC (with 470 being admitted to hospital). Based on those requiring treatment, the 2000 BJP paper outlined what the authors believed were the three main categories of the syndrome.

  • Type I: Comprises individuals that have already been diagnosed as having a psychosis (e.g., schizophrenia, bipolar illness) prior to visiting Israel. They usually travel alone and come to Israel for psychiatric religious ideation.
  • Type II: Comprises individuals with mental disorders (e.g., personality disorders, obsessions) but don’t have a clear mental illness and whose strange thoughts would not be classified as delusional or psychotic. They usually travel in groups (but sometimes alone) and come to Israel for curiosity reasons.
  • Type III: Comprises individuals that have no previous history of mental illness, but who become victim to a psychotic episode while in Israel (particularly Jerusalem). Type III individuals are said to recover spontaneously, and enjoy normality on their return to their home country. They usually travel with friends or family (often as part of an organized tour) and come to Israel as regular tourists (and have a religious home background).

The authors reported that the third type was the most was “perhaps the most fascinating” because it included individuals with no prior history of mental illness and whose symptoms were context-specific and recover spontaneously with little psychological intervention. Therefore, the authors noted that Type III Jerusalem Syndrome is not associated with other psychopathologies, and is this is a “pure” or “unconfounded” form of the syndrome. Of the 1200 or so cases, only 42 were classified as Type III.

Despite the many reported case of Jerusalem Syndrome, in subsequent responses to the BJP paper, Kalian and Witzum then disputed its existence and claimed it is just a variant of schizophrenic illness. They wrote in a letter that:

Our accumulated data indicate that Jerusalem should not be regarded as a pathogenic factor, because the morbid ideation of the affected travelers started elsewhere. Jerusalem syndrome should be viewed as an aggravation of a chronic mental illness and not a transient psychotic episode. The eccentric conduct and bizarre behavior of these colorful but mainly psychotic travelers become dramatically overt once they reach the Holy City – a geographical locus containing the axis mundi of their religious beliefs”.

The authors of the original paper then responded with yet another letter and pointed out that:

“Our initial account of Jerusalem syndrome clearly distinguished between patients with Jerusalem syndrome who also have a history of psychotic illness – Jerusalem syndrome superimposed on a previous psychotic illness – and those with no previous psychopathology, whom we referred to as having the discrete form of the syndrome. In either case, the symptoms of the syndrome appear on arrival in Jerusalem and exposure to the holy places”.

There have been a number of explanations as to why Jerusalem Syndrome occurs. Some authors suggest that mental state changes can occur as a result of a significant change in routine and circumstances  (e.g., culture clash, geographical isolation, unfamiliar surroundings, proximity to strangers and/or foreigners). These factors compounded with the religious significance to many different faiths (Christians, Jews and Muslims), may be the stimuli that to trigger acute psychotic episodes. Such ‘spiritual’ travel may represent a modern-day version of a pilgrimage. There are of course limitations of the work by Bar-El and colleagues that the authors duly acknowledge including the fact that the study (i) was based on a phenomenological description and was not a research study, (jj) lacked follow-up information, and (iii) did not taken into account changes in circumstances associated with the expected influx of tourists in the millennial year.

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

Further reading

Bar-El, Y., Durst, R., Katz, G., Zislin, J., Strauss, Z. & Knobler, H.Y. (2000) Jerusalem syndrome. British Journal of Psychiatry, 176, 86-90.

Bar-El, Y., Kalian, M. & Eisenberg, B. (1991) Tourists and psychiatric hospitalization with reference to ethical aspects concerning management and treatment. Psychiatry, 10, 487 -492.

Bar-El, I., Witztum, E., Kalian, M., et al (1991) Psychiatric hospitalization of tourists in Jerusalem. Comprehensive Psychiatry, 32, 238 -244.

Fastovsky N, Teitelbaum A, Zislin J, et al (2000). The Jerusalem syndrome. Psychiatric Services, 5, 1052.

Gordon, H., Kingham, M. & Goodwin, T. (2004). Air travel by passengers with mental disorder. The Psychiatrist, 28, 295-297.

Halim, N. (2009). Mad tourists: The “vectors” and meanings of city-syndromes. In K. White (Ed.), Configuring Madness. Oxford: Inter-Disciplinary Press.

Kalian, M. & Witzum, E. (2000) Comments on Jerusalem syndrome. British Journal of Psychiatry, 176, 492.

Kalian M. & Witzum, E. (2002) Jerusalem syndrome as reflected in the pilgrimage and biographies of four extraordinary women from the 14th century to the end of the second millennium. Mental Health, Religion and Culture, 5, 1-16.

Monden, C. (2005). Development of psychopathology in international tourists. In van Tilburg, M. & Vingerhoets, A. (Eds.), Psychological Aspects of Geographical Moves: Homesickness and Acculturation Stress (pp. 213-226). Amsterdam: Amsterdam Academic Archive.

Witztum, E., & Kalian, M. (1999). The “Jerusalem syndrome” – fantasy and reality. A survey of accounts from the 19th century to the end of the second millennium. Israelian Journal of Psychiatry and Related Sciences, 36, 260-271.