Can you feel the force? The psychopathology of ‘Star Wars’
A few days ago, my friend and colleague Dr. Andrew Dunn sent all the psychology staff members a paper published in the December 2015 issue of Australasian Psychiatry by Susan Friedman and Ryan Hall entitled ‘Using Star Wars’ supporting characters to teach about psychopathology’. As a fan of Star Wars and science fiction more generally, I immediately read the paper and thought it would be a good topic to write a blog about.
It turns out that Friedman and Ryan have written a series of papers in psychiatric journals over the last year arguing that many of the characters in the Star Wars movies have underlying psychopathologies and that because of the films’ popularity, the films could be used to teach students about various psychiatric disorders. The authors asserted that “supporting characters in Star Wars can be used to teach about a wide variety of psychiatric conditions which are not commonly so accessible in one story, including [attention deficit hyperactivity disorder] ADHD, anxiety, kleptomania, and paedophilia”. I have to admit that in my own teaching I often use characters and/or storylines from film and television to explain psychological phenomena to my own students (and have also published articles and papers demonstrating the utility of using such sources in both teaching and research contexts – see ‘Further reading’ below). Therefore, I was intrigued to read what psychiatric disorders had been attributed to which Star Wars characters.
In the Australasian Psychiatry paper, it is argued that Jar Jar Binks has attention deficit hyperactivity disorder (ADHD):
“Jar Jar frequently overlooks details and makes careless mistakes…His difficulty in sustaining his attention is evident…His difficulty in following instructions almost results in him being put to death…trainees can determine whether [the examples provided] are related to inattention, hyperactivity or impulsivity”.
More controversially, Friedman and Ryan make the case for Qui-Gon Jinn showing paedophilic grooming behaviour.
“In Phantom Menace, Qui-Gon engages in many behaviours with young Anakin Skywalker the same way a paedophile would with a child victim. Anakin seems to fit a pattern which Qui-Gon has of cultivating prepubescent, fair-complexioned boys with no strong male family ties…Anakin’s mother has no power or relations with authority, which decreases the likelihood that either she or Anakin would report the paedophile, or potentially be believed by others…Qui-Gon develops a relationship with Anakin, noting his special features and abilities: he often gives compliments to the child…He fosters a relationship where secrets are kept…and the child is slowly isolated from others…After trust is gained, there is a gradual increase in physical intimacy. In the movies this was symbolised by Qui-Gon drawing blood samples from Anakin. A paedophile may incorporate other children or older victims into the grooming process to further lower the child’s inhibitions”.
I’m not overly convinced by the argument but it does at least lead to discussions on the topic of grooming that I could see having a place in the classroom. Friedman and Ryan also examine a whole species (the Jawas) and claim that they are by nature kleptomaniacs:
“Jawas can introduce the concepts of kleptomania and hoarding, since they ‘have a tendency to pick up anything that’s not tied down’. It is important from a diagnostic point of view to recognise that kleptomania is more than just stealing or shoplifting…To meet criteria for kleptomania, one must recurrently fail to resist the impulse to steal unneeded or non-valuable objects. Tension before committing the theft is followed by gratification or release afterwards. These characteristics of kleptomania can be inferred from the Jawas’ capture of R2D2…The gratification of stealing R2D2 is clear from the Jawas’ excited scream…As for the need or value of the stolen items and the repetitive nature of the theft, the Jawas’ sandcrawler is filled with droids in various states of dysfunction…Although on a desert planet almost anything might have value, the Jawas seem to take this to extremes given the number of broken droids in their possession which do not even appear to be in good enough shape to use as spare parts”.
Elsewhere in the paper is a table listing many Star Wars characters along with “potential concept discussions” related to the characters’ behaviours in the films. This includes (amongst others) Darth Vader (borderline personality disorder, post-traumatic stress disorder), Jabba the Hutt (psychopathy and antisocial personality disorder), Boba Fett (Oedipal issues – Hamlet type), Yoda (dyslexia, malingering), Luke Skywalker (prodromal schizophrenia), Princess Leia (histrionic personality disorder), Padme Amidala (postnatal delirium, postnatal depression), Obi-Wan Kenobi (major depression in old age, pseudo-dementia), and C3PO (obsessive-compulsive personality disorder).
However, given my own research interests, the character that most interested me in Friedman and Ryan’s list was the claim that Lando Calrissian might be a pathological gambler. According to one of the Wiki entries:
“Lando Calrissian was a human male smuggler, gambler, and card player who became Baron Administrator of Cloud City, and, later, a general in the Rebel Alliance. [He] was born on the planet Socorro…During his youth, he became a smuggler and a gambler, playing a card game known as sabbacc. Calrissian was able to make a living by illegally acquiring and redistributing rare or valuable goods. However, due to Calrissian’s penchant for gambling, he and his business partner Lobot were in deep with the wrong people”.
Gambling does make the occasional appearance in Star Wars films – particularly in bar scenes. In describing Calrissian to Han Solo, Princess Leia notes “he’s a card player, gambler, scoundrel. You’d like him“. Qui-Gon Jinn notes in The Phantom Menace that “Whenever you gamble my friend, eventually you’ll lose”. The Star Wars Wiki on gambling notes that it involves “the betting of credits or possessions in wagers or games like sabbacc. For example, Lando Calrissian bet the Millennium Falcon in a game of sabacc with Han Solo, and lost. Gambling was rampant on Tatooine [the home planet of Luke Skywalker]”. The Star Wars Wiki on sabacc also notes that there are several variants of the game and that Calrissian lost the Millenium Falcon to Han Solo while playing ‘Corellian Spike’ and that Solo kept the two golden dice that were used while gambling. A profile article on Calrissian in the Washington Post describes him as a “suave gambler” rather than a pathological gambler.
There is no doubt that Calrissian liked to gamble but there is little evidence from the film that it was pathological. However, other articles (as well as older and newer fiction) about him claim that he is. For instance, in an online article by Shane Cowlishaw discussing the personality disorders of Star Wars characters, the following is claimed:
“He may have ended up leading the final assault on the Death Star, but Lando perhaps was only successful due to being a pathological gambler. Having lost the Millennium Falcon to Han Solo in a bet, conned the Bespin Gas Mine out of somebody and gambling on a deal to betray Han and Chewbacca to the Empire, it is clear he can’t help himself. Lando gambles with the lives of other rebels, albeit successfully, be demanding that the spaceship not abort their mission when Admiral Ackbar orders everyone to retreat from the unexpectedly operational Death Star. A perfect character to debate whether pathological gambling is an addiction or an impulse-control disorder, apparently”
It’s also worth mentioning that Calrissian will also be making an appearance in upcoming Marvel comics. In an interview with writer Charles Soule (who will be scripting the new stories), it is evident that the crux of his character will focus on the gambling part of his personality – but more on the problem side:
“I focused on the whole gambler archetype for Lando; more specifically, the sort of lifelong card player who never really knows when to walk away from the table. He’s always chasing his losses, hoping that if he makes a big enough bet, he can get ahead with just one good hand. It’s tweaked a bit here—the idea is that Lando had something happen to him in his past that put him way behind, and now he’s just trying to get back to even. This isn’t really a financial thing, although that’s part of it – it’s more like a moral thing. Like a life debt. I don’t hit it too hard in this story—it’s all background—but the shading is there…Lando gets into crazy, extreme situations because they’re his version of making big bets at the card table. If he can make it through his next adventure, maybe he can just retire and live a quiet life. It never really works out, though. One step forward, two steps back. That’s Lando Calrissian…It’s a story about a hyper-charismatic, ultra-smooth guy who gets into huge jams constantly, and tends to get out of them through a combination of luck and charm. He’d never punch his way out of a fight; he’d rather buy everyone a few drinks and leave on good terms. Assuming he hasn’t gambled away all his money, that is”.
However, there is also the 2013 novel Scoundrels written by Timothy Zahn featuring Calrissian, Han Solo, and Chewbacca and includes the short story Winner Lose All based on Calrissian’s love of gambling but here, there is nothing to suggest the behaviour is pathological. There is also a fictional online interview with Calrissian that puts forward the idea that he was a professional gambler rather than a pathological gambler:
“Basically I was born to a normal middle class family and found I had a talent for gambling. I traipsed across the universe as a professional gambler, but occasionally need more money so I hired out as mercenary and treasure hunter. Eventually I won the Millennium Falcon, but didn’t know how to fly it. So I paid Han Solo to teach me, he won the ship from me in a game of Sabbac. I won it back but, it like taking your best friend’s girl so I gave it back to him. When I wound up on Cloud City I won my title of Barron Administrator in a card game. The rest is they sat history”.
Finally, on a more academic note, Calrissian also makes an appearance as one of the ‘Gambler’ archetypes the book Archetypes in Branding: A Toolkit for Creatives and Strategists by Margaret Hartwell and Joshua Chen. The book is a novel approach to brand development and includes a deck of 60 archetype cards with the aim of revealing a brand’s motivation and why it attracts certain customers. The authors hope that the book will be used repeatedly to inform and enliven brand strategy. This again suggests that Calrissian’s gambling is not seen as pathological (otherwise he wouldn’t have been included in the book as a brand to be modelled upon).
Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Cowlishaw, S. (2015). Star Wars characters and their personality disorders. Stuff, July 8. Located at: http://www.stuff.co.nz/entertainment/film/70017741/Star-Wars-characters-and-their-personality-disorders
Friedman, S. H., & Hall, R. C. (2015). Using Star Wars’ supporting characters to teach about psychopathology. Australasian Psychiatry, 23(4), 432-434.
Friedman, S. H., & Hall, R. C. (2015). Teaching psychopathology in a galaxy far, far away: The light side of the force. Academic Psychiatry, 39(6), 719-725.
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.
Griffiths, M.D. (2010). Media and advertising influences on adolescent risk behaviour. Education and Health, 28(1), 2-5.
Hall, R. C., & Friedman, S. H. (2015). Psychopathology in a galaxy far, far away: The use of Star Wars’ dark side in teaching. Academic Psychiatry, 39(6), 726-732.
Hartwell, M. & Chen, J.C. (2012). Archetypes in Branding: A Toolkit for Creatives and Strategists. How Design Books.
“Turn and face the strange”: A personal goodbye to David Bowie
“There is a well known cliché that you should never meet your heroes but if David Bowie or Paul McCartney fancy coming round to my house for dinner I’m pretty sure I wouldn’t be lost for words”.
This was the last sentence I wrote in my blog on the psychology of being starstruck less than a month ago. I, like millions of others, was deeply shocked to learn of Bowie’s death from liver cancer earlier this week (January 10) two days after his 69th birthday.
I first remember hearing David Bowie on a 1975 edition of Top of the Pops (when the re-release of ‘Space Oddity’ reached No.1 in the British singles chart). Although I heard the occasional Bowie song over the next few years (‘Golden Years’, ‘Sound and Vision’ and ‘Boys Keep Swinging’ being some of the songs I taped off the radio during the weekly chart rundown) it wasn’t until ‘Ashes To Ashes’ reached the UK No. 1 spot in the week of my 14th birthday (late August 1980) that I became a Bowie convert.
I still vividly remember buying my first Bowie album – a vinyl copy of his first greatest hits LP (Changesonebowie) on the same day that I bought the third album by The Police (Zenyatta Mondatta) and the latest issue of Smash Hits (that had Gary Numan on the cover with a free yellow flexidisc of the track ‘My Face’ by John Foxx). It was Saturday October 4th, 1980. Ever since that day I’ve been collecting David Bowie music and now have every single song that he has ever commercially released along with hundreds of bootlegs of unreleased songs and live recordings.
My collection of Bowie books is ever growing and I have dozens of Bowie DVDs (both his music and films in which he has appeared). In short, I’m a hardcore fan – and always will be. Like many other fans, I’ve spent all this week listening to his final studio LP (Blackstar) and poring over the lyrics knowing that he wrote all these songs knowing that he had terminal cancer. The first line of ‘Lazarus’ appears particularly poignant in this regard (“Look up here, I’m in heaven/I’ve got scars that can’t be seen/I’ve got drama, can’t be stolen/Everybody knows me now/Look up here, man, I’m in danger/I’ve got nothing left to lose”).
Anyone who’s been a regular reader of my blog will know that when I get a chance to mention how important he has been in my life, I do so (and do so in writing). I mentioned him in my articles on the psychology of musical preferences, on the psychology of a record-collecting completist, on record collecting as an addiction, and on the psychology of pandrogyny. I’ve also mentioned him (somewhat predictably) in my articles on the psychology of Iggy Pop, and the psychology of Lou Reed (two more of my musical heroes).
I’ve also been sneaking the titles of his songs into the titles of my blog articles ever since I started my blog including ‘Space Oddity’ (in my article on exophilia), ‘Holy Holy’ (in my article on Jerusalem Syndrome), ‘Ashes To Ashes’ (in my article on ‘cremainlining‘), ‘Under Pressure’ (in my article on inflatable rubber suit fetishism), and ‘Changes’ (in my article on transformation fetishes).
When I started writing this article I did wonder whether to do ‘the psychology of David Bowie’ but there is so much that I could potentially write about that it would take more than a 1000-word blog to do any justice to one of the most psychologically fascinating personalities of the last 50 years (Strange Fascination by David Buckley being one of the many good biographies written about him).
Trying to get at the underlying psychology of someone that changed personas (‘the chameleon of pop’) so many times during his career is a thankless task. However, his desire for fame started early and he was determined to do it any way he could whether it was by being a musician, a singer, an actor, a mime artist, an artist, or an entrepreneur (arguably he has been them all at one time or another). Being behind a mask or creating a persona (or “alternative egos” as Bowie called them) was something that got Bowie to where he wanted to be and I’m sure that with each new character he became, the personality grew out of it.
As an academic that studies addiction for a living, Bowie would be a perfect case study. Arguably it could be argued that he went from one addiction to another throughout his life, and based on what I have read in biographies a case could be made for Bowie being addicted (at one time or another) from cocaine and nicotine through to sex, work, and the Internet.
Bowie also had a personal interest in mental health and various mental disorders ran through his family (most notably his half-brother Terry Burns who was diagnosed as a schizophrenic and committed suicide in January 1985 by jumping in front of a moving train. A number of his aunts were also prone to clinical depression and schizophrenia). Bowie first tackled his “sad [mental] inheritance” in ‘All The Madmen’ (on his 1971 The Man Who Sold The World LP) and was arguably at his most candid on the 1993 hit single ‘Jump They Say’ that dealt with is brother’s mental illness and suicide.
Like John Lennon, I’ve always found Bowie’s views on almost anything of interest and he was clearly well read and articulate. He described himself as spiritual and recent stories over the last few days have claimed he almost became a Buddhist monk. Whether that’s true is debatable but he was certainly interested in Buddhism and its tenets. Now that I am carrying out research into mindfulness with two friends and colleagues who are also Buddhist monks (Edo Shonin and William Van Gordon), I have begun to read more on the topic. One of the things that Buddhism claims is that identity isn’t fixed and nowhere is that more true than in the case of David Bowie. Perhaps the chorus one of his greatest songs – ‘Changes’ from his 1971 Hunky Dory LP says it all:
Ch-ch-ch-ch-changes/Turn and face the strange/Ch-ch-changes/Don’t want to be a richer man/Ch-ch-ch-ch-changes/Turn and face the strange/Ch-ch-changes/Just gonna have to be a different man/Time may change me/But I can’t trace time”
Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Buckley, D. (2005). Strange Fascination: David Bowie – The Definitive Story. London: Virgin Books.
Cann, K. (2010). Any Day Now: David Bowie The London Years (1947-1974). Adelita.
Goddard, S. (2015). Ziggyology. London: Ebury Press.
Hewitt, P. (2013). David Bowie Album By Album. London: Carlton Books Ltd.
Leigh, W. (2014). Bowie: The Biography. London: Gallery.
Pegg, N. (2011). The Complete David Bowie. London: Titan Books.
Seabrook, T.J. (2008). Bowie In Berlin: A New Career In A New Town. London: Jawbone.
Spitz, M. (2009). Bowie: A Biography. Crown Archetype.
Trynka, P. (2011). Starman: David Bowie – The Definitive Biography. London: Little Brown & Company.
Water feature: A brief look at psychogenic polydipsia, hyponatraemia, and ‘aquaholism’
Over the weekend I went to the cinema with my oldest son to watch Mad Max: Fury Road. The reason I mention this is because King Immortan Joe in the film (who live in a world where water is a scarce commodity) tells his thirsty subjects “Do not become addicted to water, it will take hold of you”. As soon as I got home after the film, I was straight onto Google and Google Scholar to see whether there had been anything written on ‘water addiction’. Unsurprisingly, there were lots of newspaper reports of individuals being ‘addicted’ to water but little in the academic literature. For instance, one American online article told the story of Sasha Kennedy:
“[Sasha] is addicted to water, drinking 25 liters of the stuff a day, far exceeding the USDA Recommended Daily Water Intake of 2.7 liters…What surprised me most was that the condition had a name: Psychogenic polydipsia. It is ‘an uncommon clinical disorder characterized by excessive water-drinking in the absence of a physiologic stimulus to drink’ and is typically found among mental patients on phenothiazine medications. Kennedy appears to be completely sane, although she does experience the dry mouth sensation characteristic of the condition…You’d think drinking so much water would do something to her health, but medical experts confirmed that there is nothing wrong with her. She doesn’t even have hypoatremia, where cells swell due to too much water in the blood. She’s perfectly healthy and her blood isn’t diluted. Then again, her habit started when she was two years old, so maybe her body acclimatized. Her lifestyle, however, is drastically affected by her addiction. She has to go to the toilet 40 times a day and can only get about an hour of sleep every night before having to wake up to drink some water or go to the loo. She carries large bottles of water with her everywhere she goes, and once quit her job because the tap water quality wasn’t up to par”.
Another case was reported by the UK’s Daily Mail who recounted the story of 22-year old “aquaholic” Sarah Schapira who (at the time the article was written) drank seven litres of water every day, and like Sasha above spent a lot of time in the toilet. Schapira stated:
“My argument has always been that water is good for you and helps you to detox. We’ve all been told about the benefits of water, so I drink lots and lots of it, from the minute I wake up to the minute I go to bed. If I don’t have my bottle of water I feel paranoid. And if I try not to drink for an hour, I start to feel dehydrated and I get throbbing headaches. But it has got to the stage where I don’t know how to give it up. It used to make me feel really good and healthy but not any more. I know I ought to cut down but I’m not sure how I can”.
Polydipsia (which in practical terms means drinking more than three litres of water a day) often goes hand-in-hand with hyponatraemia (i.e., low sodium concentration in the blood) and in extreme cases can lead to excessive water drinkers slipping into a coma. The low levels of sodium causes the brain to swell which in turn constricts the blood supply to the brain when the brain compresses against the skull’s inner surface. Another person interviewed for the Daily Mail story was 26-year-old Rachel Bennett, a marketing agent from North London who drank also drank seven litres of water a day which led to headaches and dizziness. She said:
“My friends used to tease me about the amount I drank, but I dismissed their fears because I always thought it was so good for me. It got to the stage where I felt I couldn’t function without it. If I woke without a bottle of water by my bed, I would feel really paranoid. I couldn’t drink tap water – that tasted awful – instead I drank Evian by the gallon. It’s expensive, too – I could spend over £30 a week on water – but I had got to the stage where I got a huge buzz from drinking so much”.
In researching this article, I was surprised to find dozens and dozens of academic papers on psychogenic polydipsia (PPD). For instance, a paper by Dr. Brian Dundas and colleagues in a 2007 issue of Current Psychiatry Reports noted that PPD is a clinical syndrome characterized by polyuria (constantly going to the toilet) and polydipsia (constantly drinking too much water), and is common among individuals with psychiatric disorders. They also noted that:
“The underlying pathophysiology of this syndrome is unclear, and multiple factors have been implicated, including a hypothalamic defect and adverse medication effects. Hyponatremia in PPD can progress to water intoxication and is characterized by symptoms of confusion, lethargy, and psychosis, and seizures or death. Evaluation of psychiatric patients with polydipsia warrants a comprehensive evaluation for other medical causes of polydipsia, polyuria, hyponatremia”.
A 2000 study in European Psychiatry by Dr. E. Mercier-Guidez and Dr. G. Loas examined water intoxication in 353 French psychiatric inpatients. They reported that water intoxication can lead to irreversible brain damage and that around one-fifth of deaths among schizophrenics below the age of 53 years are caused this way. The study reported that 38 of the psychiatric patients (11%) suffered from polydipsia with one-third of them at risk of water intoxication. They also reported that being polydipsic was significantly associated with being male, a cigarette smoker and celibate. Those with polydipsia were highly prevalent among those with schizophrenia, mental retardation, pervasive developmental disorders and somatic disorders.
A comprehensive review by Dr. Victor Vieweg and Dr. Robert Leadbetter in the journal CNS Drugs examined the polydipsia-hyponatraemia syndrome (PHS). They reported that PHS occurs in approximately 5%-10% of institutionalised, chronically psychotic patients, of which four-fifths have schizophrenia. Major clinical features are polydipsia and dilutional hyponatraemia. Patents with PHS can experience delirium, generalised seizures, coma and death. The main ways to treat such individuals are fluid restriction, daily bodyweight monitoring, behavioural approaches, and supplemental oral sodium chloride administration. However, these interventions can be expensive as they require experienced and dedicated multidisciplinary staff. They also report that:
“A number of pharmacological treatments have been assessed for PHS including the combination of lithium and phenytoin, demeclocycline, propranolol, ACE inhibitors, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors, typical antipsychotic drugs, clozapine and risperidone. Of these agents, the most promising are the combination of lithium and phenytoin, and clozapine…Long term strategies include behavioural interventions and the combination of lithium and phenytoin, and clozapine”.
Unsurprisingly, I found almost nothing on being addicted to water. A 2010 review article on PPD by Dr. D. Hutcheon and Dr. M. Bevilacqua in the Annals of the American Psychotherapy Association claimed:
“One way to assess a patient’s ability to limit polydipsia is to examine their objective reasons why polydipsia is so important in their lives. This can be initiated during psychosocial rehabilitation group meetings held semi-weekly (e.g., two 15-minute sessions per week). In these meetings, many patients have described a euphoric quality associated with polydipsia, although others have admitted to increased irritability. Most patients have noted a desire for stimulation, similar to other substances of abuse such as alcohol or street drugs. Developing an understanding of what influences a patient to develop an addiction for polydipsia can improve management of this dysregulation of fluid intake…During the treatment period in a structured inpatient setting, many patients diagnosed with psychogenic polydipsia, whether falling in the range of mild, moderate, or severe addiction, are unable to sustain a comfortable discharge to an open ward…psychogenic polydipsia can become an addiction with no demonstrable cure if left untreated… Due to the nature of the addiction and potential for self-injurious behavior, treatment requires a milieu that balances maximizing the patients’ dignity with their safety, which demands close scrutiny by the multidisciplinary team”.
I also found an old case study from a 1973 issue of the British Journal of Addiction on ‘water dependence’. This paper reported that the excessive drinking of water can dilute electrolytes in an individual’s brain and cause intoxication. A couple of papers by Dr. Bennett Foddy and Dr. Julian Savulescu have cited this case study in their own writings on addiction. In a 2010 issue of Philosophy, Psychiatry and Psychology, they noted:
“Of course, it can be claimed that a person who is addicted to sugar or water is diseased, and that their brain has changed in such a way as to make their sugar- or water-seeking behavior involuntary. Yet we know how sugar interacts with the brain to form a sensitization effect, and it is identical to how drugs – and sugar – interact with the brain of a non-addicted person. If addictions are formed through a pharmacological process, it is the exact same process that forms a person’s likes and dislikes of any pleasurable stimulus. Terms like ‘addiction’ and ‘dependence’ can reasonably be employed when a person’s likes become particularly strong, but it should be understood that these terms denote a difference in degree, not a difference in kind…The only relevant difference between drugs and sugar is that drugs produce a higher level of brain reward relative to the volume of the dose. It is easier to get addicted to heroin than to sugar, because you can do it by taking a quarter gram at a time. It is very hard to get addicted to water, because you must force down liters of it every day”.
This interesting extract argues that it is theoretically possible for someone to become addicted to water and that there is no real difference to drug addictions in terms of conceptualization and mechanism – just that the sheer amount of water that needs to be drunk to have a negative effect is large and highly unlikely.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Daily Mail (2005). Aquaholics: Addicted to drinking water. May 16. Located at: http://www.dailymail.co.uk/health/article-348917/Aquaholics-Addicted-drinking-water.html
de Leon, J., Verghese, C., Tracy, J. I., Josiassen, R. C., & Simpson, G. M. (1994). Polydipsia and water intoxication in psychiatric patients: a review of the epidemiological literature. Biological Psychiatry, 35(6), 408-419.
Dundas, B., Harris, M., & Narasimhan, M. (2007). Psychogenic polydipsia review: etiology, differential, and treatment. Current Psychiatry Reports, 9(3), 236-241.
Edelstein, E.L. (1973). A case of water dependence. British Journal of Addiction to Alcohol and Other Drugs, 68, 365–367.
Foddy, B., & Savulescu, J. (2007). Addiction is not an affliction: Addictive desires are merely pleasure-oriented desires. American Journal of Bioethics, 7(1), 29-32
Foddy, B., & Savulescu, J. (2010). A liberal account of addiction. Philosophy, Psychiatry, and Psychology, 17(1), 1-22.
Hutcheon, D., & Bevilacqua, M. (2010). Psychogenic polydipsia: A review of past and current interventions for treating psychiatric inpatients diagnosed with psychogenic polydipsia (PPD). Annals of the American Psychotherapy Association, 13(1). Located at: http://www.biomedsearch.com/article/Psychogenic-polydipsia-review-past-current/222558218.html
Teoh, S.Y. (2012). Woman addicted to water drinks 100 glasses a day. The Mary Sue, July 12. Located at: http://www.themarysue.com/woman-addicted-to-water/#geekosystem
Vieweg, W.V.R., & Leadbetter, R.A. (1997). Polydipsia-Hyponatraemia Syndrome. CNS Drugs, 7(2), 121-138.
Verghese, C., de Leon, J., & Josiassen, R. C. (1996). Problems and progress in the diagnosis and treatment of polydipsia and hyponatremia. Schizophrenia Bulletin, 22(3), 455-464.
French connections: A beginner’s guide to Paris Syndrome
While researching a previous blog on Stendhal Syndrome, I came across various references to a number of “city syndromes”. According to an interesting book chapter by Nadia Halim, city syndromes are “acute, (usually) short-lived disorders that have in common a similar set of symptoms and pattern of onset and recovery”. Each of the city syndromes that have been identified in the psychological literature is associated with a specific tourist destination (e.g., Jerusalem, Paris, Florence) and identified by medical practitioners (usually psychiatrists) when sufferers access mental health services. In essence, the condition is a type of ‘culture shock’ where an individual becomes psychologically disorientated when they experience new environments that feel alien to them.
One such city syndromes is ‘Paris Syndrome’, a psychological condition that appears to affect Japanese tourists only, suggesting that it is some kind of culture bound syndrome. According to an article in the BBC News, Paris Syndrome was first identified in 1986 by Professor Hiroaki Ota (a Japanese psychiatrist who was working in France at the time). The condition is said to cause mental breakdown when visiting the city. The incidence of the disorder is very small as reports estimate that only 10-20 people a year suffer out of millions of tourists. However, the only ‘cure’ is for the affected individuals to return back to Japan.
As far as I am aware, there are only a couple of academic papers that have been published on Paris Syndrome. The first one was a case study published in a 1998 issue of the Journal of the Nissei Hospital by Dr. Katada Tamami. This was a report of a male manic-depressive who shortly after visiting Paris presented with symptoms of insomnia, fluctuation of mood, aggression, irritation and increase in sex drive. Tamami noted that being separated from his family, and living alone in Paris, the man had an identity crisis as in Paris he was no longer a father or professor. His fantasy and idealization of Paris played a large part in his abnormal behaviour.
The second paper was by a group of French psychiatrists in a 2004 issue in the French psychiatry journal Nervure. The authors reported that between 1988 and 2003, a total of 63 Japanese patients had been hospitalized because of the condition (with a slight bias towards females in their 30s). Although the number of affected patients was relatively low, the Japanese Embassy arranged for a Japanese psychiatrist to work in the authors’ hospital (i.e., St. Anne’s Hospital). In fact, the Japanese Embassy has a 24-hour telephone hotline for Japanese tourists suffering from severe culture shock. The paper claimed that for affected individuals, the city of Paris held a “quasi-magical” attraction and that it was characteristically “symbolic of all the aspects of European culture that are admired in Japan”. A Wikipedia article on Paris Syndrome claims that: “the susceptibility of Japanese people may be linked to the popularity of Paris in Japanese culture”. The same article also noted that:
“Mario Renoux, the president of the Franco-Japanese Medical Association, states in Liberation’s article ‘Des Japonais entre mal du pays et mal de Paris” (December 13, 2004) that Japanese magazines are primarily responsible for creating this syndrome. Renoux indicates that Japanese media, magazines in particular, often depict Paris as a place where most people on the street look like fashion models and most women dress in high-fashion brands”.
The symptoms of Paris Syndrome are typically transient and include anxiety attacks, violent and aggressive outbursts, feelings of persecution, acute psychotic delusions (of paranoia, megalomania, erotomania and/or mysticism), dissociative and/or disoriented feelings, depersonalization, derealization, psychomotor abnormalities (e.g., dizziness, sweating, tachycardia), and – in some cases – thoughts of suicide. Interviews with the affected individuals revealed that the Japanese arrive in the city with highly romanticized expectations and that many had spent years dreaming of coming to Paris before doing it in actuality.
The authors of the paper published in Nervure identified two fundamentally different types of the syndrome based on previous psychiatric problems and when the symptoms occurred:
- Type 1 [Classic]: These individuals typically have a problematic psychiatric history and may travel to Paris for idiosyncratic “strange” or delusional reasons. However, the onset of the symptoms is immediate upon arrival in Paris (and may even begin in the airport).
- Type 2 [Delayed Expression]: These individuals do not usually have a personal and/or familial psychiatric history. The reasons for visiting Paris are typically for ‘normal’ travelling reasons but the onset of the symptoms is much later than the ‘classic’ type (i.e., three months or longer after arriving in Paris).
As an example of the first type of sufferer, the paper described the case of a 39-year-old Japanese woman with a history of schizophrenia that was hospitalized following a psychotic breakdown on her immediate arrival in Paris. She had come to Paris following an advertizing campaign that had the tagline: “France is waiting for you”. She took it to mean it was her personal destiny to go there and claimed she was going to become the queen of one of the Scandinavian countries (“Sweden, Finland or Denmark”). As an example of the second type of sufferer, the paper described the case of a 30-year-old Japanese man with no previous psychiatric history who came to France for educational reasons. The onset of the symptoms was five months after arriving in France and started when he moved into a Paris hotel (after initially studying in Reims). He was hospitalized after experiencing severe anxiety, insomnia, anorexia, and auditory hallucinations (i.e., voices threatening to kill him and his family).
One of the factors that appear to be common among sufferers is that they appear to be highly unprepared for the reality of day-to-day life in the city (e.g., the marked cultural differences, the great difference in language, the difference in public manners and behaviours, etc.). It is these differences that appear to act as a trigger for the onset of the behaviour. The most salient trigger for Paris Syndrome is thought to be the language barrier. Another factor appears to be intense exhaustion caused by trying to cram in as much as possible in the short time available for sightseeing alongside the effects of jetlag. Such factors are said to contribute to the psychological destabilization of some Japanese visitors. Another French physician (Youcef Mahmoudia) working at the hospital Hotel-Dieu de Paris claimed that Paris Syndrome was “a manifestation of psychopathology related to the voyage, rather than a syndrome of the traveller” and hypothesized that it was the excitement resulting from visiting Paris that caused the psychosomatic symptoms (e.g., increased heart rates, dizziness, etc.).
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Angelique, C. (2006). Paris syndrome hits Japanese. The Guardian, October 25. Located: http://www.guardian.co.uk/world/2006/oct/25/japan.france
Fastovsky N, Teitelbaum A, Zislin J, et al (2000). The Jerusalem syndrome. Psychiatric Services, 5, 1052.
Halim, N. (2009). Mad tourists: The “vectors” and meanings of city-syndromes. In K. White (Ed.), Configuring Madness. Oxford: Inter-Disciplinary Press.
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.
Tamami, K. (1998). Reflexions on a case of Paris syndrome. Journal of the Nissei Hospital, 26, 127-132.
Viala, A., Ota, H., Vacheron, M.N., Martin, P., & Caroli, F. (2004). Les Japonais en voyage pathologique à Paris: Un modèle original de prise en charge transculturelle. Nervure (supplement), 17(5), 31-34.
Wikipedia (2012). Paris Syndrome. Located at: http://en.wikipedia.org/wiki/Paris_syndrome
Wyatt, C. (December 20, 2006). Paris Syndrome strikes Japanese. BBC News, December 20/ Located at: http://news.bbc.co.uk/1/hi/6197921.stm
“I see dead people”: Are hallucinations always bad?
I have to admit that I know relatively little about the neuropsychology of hallucinations. The only time I have written about them in scientific journals is in the context of excessive video gaming where there are case studies of people who appear to display auditory and/or visual game-related hallucinations, and may be part of a wider repertoire of sensory consequences of video game playing that we have coined ‘game transfer phenomena’ (and which I outlined in a previous blog).
However, in a completely different context, I recently came across a really interesting 2011 case study by Dr. Amin Gadit who published a short paper in BMJ Case Reports entitled ‘Insightful hallucination: psychopathology or paranormal phenomenon?’ Dr. Gadit noted that hallucinations are usually indicative of a serious psychiatric problem (i.e., typically some kind of psychosis) and typically require treatment. However, Dr. Gadit described the case of a 26-year old successful Pakistani businessman who was suffering hallucinations but experienced a dilemma as to whether to treat him or not because his hallucinations appeared to be providing some therapeutic benefit to his patient.
The man was married to his first cousin (also from Pakistan) and was described as being “extremely close” to his mother. Dr. Gadit reported that his patient’s wife sometimes got extremely upset (which I interpreted as being jealous) about her husband’s attachment to his mother. Following the mother’s diagnosis of a terminal illness with only a few months left to live, the man (understandably given the relationship with his mother) experienced deep emotional turmoil and upset. Dr. Gadit wrote that according to his patient that:
“[His] mother told him before dying that she would remain in contact with him after death. The patient went through a complicated bereavement period when she died. However, 6 months later, he regained his cheerful mood and started taking an interest in business again. His wife noticed that he was talking to himself for at least an hour each day. When asked, he said that his mother visits him every day and he talks to her. This was his firm belief. There was no deterioration in his personality and no other features worthy of note”.
Following these episodes of speaking to his dead mother almost every night at different times in the evening, the man’s wife persuaded him to seek psychiatric help. Dr. Gadit claimed that his patient resented being in treatment and argued that the regular “contact” with his dead mother was a positive experience and made the man happy and helped bring normality to his day-to-day life. Following initial psychiatric assessment, Dr. Gadit noted that:
“There was no significant medical history or family history indicative of any mental disorder. A thorough clinical history revealed nothing except this hallucination. The patient had retained insight as he believed that this would not happen normally but in his case was a special occurrence. He attributed this to his Muslim belief of God’s blessing in sending his mother back to him in this way. His physical examination was unremarkable and all laboratory results were normal. MRI did not reveal any pathology. His mental state examination revealed normothymic mood, delusion, visual hallucination, psychosis (with no supporting evidence), intact cognitive function and reasonable insight into his problem”.
The man’s mother appeared most evenings wearing different dresses (ones that she used to wear when she was alive) but he said his mother would not allow him to touch her when she appeared. The man was adamant that his mother appeared before him in the real world and refused any medical treatment. Organ pathology (often associated with auditory hallucinations) was ruled out as a cause, and there was insufficient evidence for a diagnosis of schizophrenia (often associated with auditory hallucinations). Ultimately, Dr. Gadit did not reach a psychiatric diagnosis and he sought a second opinion (which also failed to produce a diagnosis). The lack of formal diagnosis posed a dilemma in terms managing the presenting condition. The man had monthly appointments for over half a year with Dr. Gadit but the condition remained constant. In discussing the case, Dr. Gadit wrote that:
“The patient recognises the hallucination (perception without the presence of an external stimulus) as happening in the real world. It is important to differentiate true hallucination from ‘pseudo-hallucination’ and ‘imagery’. A pseudo-hallucination is an involuntary sensory experience vivid enough to be regarded as a hallucination but recognised by the patient as not the result of external stimuli; it would not be considered by the person to be ‘real’. Imagery is a collection of images used to create a sensory experience and is the element in a literary work used to evoke mental images and stimulate an emotional response. In the current case report, the patient believes that he can see and talk to his mother in the real world and that he is not imagining it”.
In discussing the case in relation to previous literature, Gadit made reference to a 2009 paper by H. Haween in the Dartmouth Undergraduate Journal of Science (DJUS) that reported hallucinations following bereavement typically resolve over time. Such hallucinations are most commonly in reported during the grieving process in males aged 25 to 30 years. Other similar non-psychiatric illnesses include Charles Bonnet’s Syndrome (typical sufferers being the elderly) that comprises clear hallucinations experienced among visually impaired individuals. A study dating back to 1971 by Dr. W.D. Rees and published in the British Medical Journal reported ‘widowhood hallucinations’ in 14% of Welsh widows and widowers (n=293). A more recent study in a 2002 issue of the British Journal of Psychiatry, a team led by Dr. L.C. Johns reported a 4% prevalence of hallucinations in white and ethnic minority populations and suggested that hallucinations are not always associated with psychotic disorders.
Gadit claimed that his male case study was “unique” as the persistent hallucinations resulted in no noticeable psychopathology, and appeared beneficial to his patient. He also speculated that the visions might be a paranormal experience or “a case of hallucinosis with a secondary delusional explanation”. Gadit claimed that paranormal phenomena are fairly common in both the developed and the developing world (and typically associated with rituals and myths).
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Gadit, A.A.M. (2011). Insightful hallucination: psychopathology or paranormal phenomenon? BMJ Case Reports 2011; doi:10.1136/bcr.10.2010.3456
Heewan K. (2009). Hallucination: a normal phenomenon? Dartmouth Journal of Undergraduate Science, November 21. Located at: http://dujs.dartmouth.edu/fall-2009/hallucination-a-normal-phenomenon
Johns, L.C., Nazroo, J.Y., Bebbington, P., et al. (2002). Occurrence of hallucinatory experiences in a community sample and ethnic variations. British Journal of Psychiatry, 180, 174-178.
Menon, G.J., Rahman, I. & Menon, SJ, et al. (2003) Complex visual hallucinations in the visually impaired: the Charles Bonnet Syndrome. Survey of Ophthalmology, 48, 58-72.
Ortiz de Gotari, A., Aronnson, K. & Griffiths, M.D. (2011). Game Transfer Phenomena in video game playing: A qualitative interview study. International Journal of Cyber Behavior, Psychology and Learning, 1(3), 15-33.
Rees, W.D. (1971). The hallucinations of widowhood. British Medical Journal, 4, 37-41.
Spence, S. A. (1993). Nintendo hallucinations: A new phenomenological entity. Irish Journal of Psychological Medicine, 10, 98–99.
Cock tales: A brief look at Penile Dysmorphic Disorder
In a previous blog, I examined Body Dysmorphic Disorder (BDD). At its simplest level, BDD is a distressing, handicapping, and/or impairing preoccupation with an imagined or slight defect in body appearance that the sufferer perceives to be ugly, unattractive, and/or deformed. BDD sufferers can think about their perceived defect for hours and hours every day. The International Classification of Diseases (ICD-10) criteria for BDD is:
- Persistent belief in the presence of at least one serious physical illness underlying the presenting symptom(s), even though repeated investigations and examinations have identified no adequate physical explanation, or a persistent preoccupation with a presumed deformity or disfigurement.
- Persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or abnormality underlying the symptoms.
One particular body part that has been the focus of some research in the BDD field is that of genitalia. Many men worry about the size of their penis and think it is too small. This is perfectly normal and the worry or concern is highly unlikely to be a symptom of BDD. In a 2004 issue of the Postgraduate Medical Journal, British psychiatrist Dr David Veale reported that although there are broad similarities between the genders in BDD, there are some differences. For instance, men with BDD show a greater preoccupation with their genitals, and women with BDD are more likely to have a co-morbid eating disorder. Dr. David Sarwer (writing in a 2006 issue of Plastic and Reconstructive Surgery) asserted that the rate of body dysmorphic disorder should be examined among patients re-questing atypical procedures and cites the example of those individuals requesting genital surgery.
Back in 2008, Channel 4 in the UK had a television series called Penis Envy. The first episode (The Perfect Penis) featured a US psychology student who paid $4000 to have his penis lengthened by cutting the ligament in his pubis. Such actions might be indicative of BDD but the programme didn’t explore this facet. Following such operations, men then have to spend the following weeks suspending a weight from their penis for at least eight hours a day. For all the financial and physical burdens faced, the average increase in length is only 0.5-3cm (with official statistics being closer to 0.5cm than 3cm). Other methods of increasing genital size include the injection of silicon into the penis (although this is dangerous and can result in a silicon embolism).
Dr. Stephen Snyder (Associate Clinical Professor of Psychiatry, Mount Sinai School of Medicine, New York, US) was interviewed about (so-called) ‘Penile Dysmorphic Disorder’ (PDD) in an online Psychology Today article. He was quoted as saying:
“I don’t know of any statistics on [PDD]. Anxiety or insecurity about penis size is extremely common in men. It would be difficult to determine how frequently the more serious condition of penis-focused BDD occurs. People with BDD tend to avoid mental health specialists…It’s much more likely I think that a man with penile BDD will purchase penis enlargement equipment or consult a surgeon than consult someone like me…Some people seem to have an innate tendency for obsessive thinking. Why some of these people develop BDD, and others OCD or Anorexia Nervosa is unknown…A man who begins to obsess about the size of his penis may begin to compulsively and repeatedly measure his erections, and to avoid dating because he’s convinced he’ll be humiliated. Then the whole thing can spiral out of control, until ultimately he’s online studying penis enlargement techniques”.
A 2006 study led by Dr. J. Lever and published by Psychology of Men and Masculinity reported that in an online survey of over 52,000 participants, most male participants rated their penis as average (66%) and only 22% as large and 12% as small. Among the female participants, around 85% of women were satisfied with their partners’ penile size, while only 55% of men were satisfied, with 45% wanting to be larger (and 0.2% to be smaller).
Just recently, Dr. Warren Holman highlighted the case of ‘Sam’, a 17-year-old white male from a middle-class Jewish family living in Midwest USA with penile dysmorphic disorder (in a 2012 issue of Social Work in Mental Health). As Dr. Holman reported:
“Sam had stopped attending school several weeks earlier, and on many days would not even leave his home. He said he wanted to remain at home and away from school because, ‘My penis is shrinking and people can tell.’ Sam reported he had had his anxiety about his penis for about a year, but until recently had been able to reason himself out of it…Sam was well related, and his mental status was unremarkable except for his belief about his penis”.
Dr. Holman believed that Sam’s conviction that his penis was shrinking (and people could tell) suggested three possible diagnoses (i.e., social phobia; BDD and/or delusional disorder of the somatic type; or schizophrenia). Holman eventually reached the conclusion that Sam’s beliefs were due to BDD although did say that it “may be in a prodromal phase of schizophrenia”. Sam was treated via a form of psychodynamic counselling (which much to the disappointment of Holman ultimately failed perhaps because of initial misdiagnosis).
In 2007, British urologists Dr. Kevan Wylie and Dr. Ian Eardley published a review on penile size in BJU International. They summarized all of the studies on penile size that have examined flaccid penis length, stretched penis length, erect penis length, flaccid penis girth and erect penis girth. They reported that:
“Stretched penile length in these studies was typically 12–13 cm, with an erect length of 14–16 cm. For girth, there was again remarkable consistency of results, with a mean girth of 9–10 cm for the flaccid penis and 12–13 cm for the erect penis…Concern over the size of the penis, when such concern becomes excessive, might present as the ‘small penis syndrome’ [SPS], an obsessive rumination with compulsive checking rituals, body dysmorphic disorder, or as part of a psychosis”.
However, they did also assert that more research was required on the effects of race and age on penile length. Wylie and Eardley speculate that SPS (or ‘locker room syndrome’ as they also call it) originates in childhood following the sight of their father’s, elder sibling’s and/or older friend’s penis. This appears to have support from a 2005 study (also published in BJU International). Dr. N. Mondaini and Dr. P. Gontero surveyed men who thought they had a small penis at an andrology clinic and reported that nearly two-thirds said their SPS had begun in childhood (63%) with the rest saying it began in adolescence (37%).
Wylie and Eardley also examined the treatment options of men with SPS and also examined the evidence of commercial penis extending techniques. They concluded that:
“It is recommended that the initial approach to a man who has SPS is a thorough urological, psychosexual, psychological and psychiatric assessment that might involve more than one clinician…Conservative approaches to therapy, based on education and self-awareness, as well as short-term structured psychotherapy [cognitive-behavioural therapy] are often successful, and should be the initial interventions in all men. Of the physical treatments available, there is poorly documented evidence to support the use of penile extenders. More information is need on the outcomes with these devices. Similarly, there is emerging evidence about the place of surgery and there are now several reports suggesting that dividing the suspensory ligament can increase flaccid penile length”.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Goodman, M.P. (2009). Female Cosmetic Genital Surgery. Obstetrics and Gynecology, 113, 154-159.
Holman, W.D. (2012). “My Penis Is Shrinking and People Can Tell”: A Confusing Case of Apparent Body Dysmorphic Disorder. Social Work in Mental Health, 9, 319-335.
Morrison, T.G., Bearden, A., Ellis, S.R. & Harriman, R. (2005). Correlates of genital perceptions among Canadian post- secondary students. Electronic Journal of Human Sexuality, 8. Located at: http://www.ejhs.org/volume8/GenitalPerceptions.htm
Lever, J., Fredereicjk, D.A. & Peplau, L.A. (2006). Does size matter? Men’s and women’s views on penis size across the lifespan. Psychology of Men and Masculinity, 3,129-143.
Mondaini, N. & Gontero, P. (2005). Idiopathic short penis: myth or reality? BJU International, 95, 8–9.
Sarwer, D.B. (2006). Body Dysmorphic Disorder and cosmetic surgery. Plastic and Reconstructive Surgery, December, 168e-180e.
Snyder, S. (2011). When size obsession gets out of hand. Psychology Today, June 11. Located at: http://www.psychologytoday.com/blog/sexualitytoday/201106/when-size-obsession-gets-out-hand
Sondheimer, A. (1988). Clomipramine treatment of delusional disorder-somatic type. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 188-192.
Veale, D. (2004). Body dysmorphic disorder. Postgraduate Medical Journal, 80, 67-71.
Wylie, K.R. & Eardley, I. (2007). Penile size and the ‘small penis syndrome’. BJU International, 99, 1449–1455.
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
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.
An eye for an I! A beginner’s guide to auto-enucleation
I have to say that I have no idea what it must be like to lose an eye (i.e., enucleation) but one thing I can’t possibly begin to imagine is what it must like is to remove my own eye (i.e., auto-enucleation). However, there are many clinical and medical reports of people that self-mutilate by stabbing or removing their eye(s). Arguably the most infamous auto-enucleator was Oedipus (in Sophocles’ play) who removed both his eyes after he realized he had unwittingly slept with his own mother and killed his own father.
The psychiatrist Dr. Armando Favazza defines self-mutilation as “the deliberate, direct, non-suicidal destruction or alteration of one’s body tissue”. Dr. Niraj Ahuja and Dr. Adrian Lloyd writing in the Australian and New Zealand Journal of Psychiatry also add that self-mutilation relates to bodily self-damage without wishing to die. Dr. Favazza also believes there are three fundamentally different types of self-mutilation. Enucleation is included in the first type (major self-mutilation) and is the least common. Other forms of self-mutilation in this category include self-castration, penectomy (cutting off one’s own penis) and self-limb amputation.
The second type includes “monotonously repetitive and sometimes rhythmic acts such as head-banging, hitting, and self-biting” (which according to Dr Favazza occur mostly in “moderate to severely mentally retarded persons as well as in cases of autism and Tourette’s syndrome”). The final and most common forms of bodily self-mutilation are moderately superficial and include a compulsive sub-type (e.g., hair-pulling, skin scratching and nail-biting), as well as an episodic/repetitive sub-type (e.g., skin-cutting, skin carving, burning, needle sticking, bone breaking, and wound picking). Many of these self-harming behaviours are a symptom and/or an associated feature in a number of mental personality disorders (e.g., anti-social, borderline, and histrionic personality disorders).
Reports of auto-enucleation in the medical literature were first described in the 1840s. By the early 1900s, the act of removing one’s own eye was actually termed ‘Oedipism’ by Blonel. Auto-enucleation is (of course) exceedingly rare although a couple of studies in the American Journal of Ophthalmology (in 1984) and an analysis of 1,146 enucleations between 1980 and 1990 in the British Journal of Ophthalmology (in 1994) estimated there were 2.8 to 4.3 per 100,000 in the population. However, some papers (such as those by Dr. Favazza) on major self-mutilation have put the incidence as low as one in 4 million.
Enucleators are also known to be at increased risk of further self-harming, and (predictably) are more likely to be living in psychiatric institutions when the auto-enucleation event occurs. They are also at increased risk of removing the second eye at a later date if they didn’t pull out both eyes to start with. A review by Dr. H.R. Krauss and colleagues in a 1984 issue of the Survey of Opthalmology examined 50 cases of self-enucleation and reported that 19 of them had bilateral auto-enucleation (i.e., had removed both of their eyes). A 2007 paper by Dr. Alireza Ghaffari-Nejad and colleagues in the Archives of Iranian Medicine examined the many theories behind self-harming behaviour. They briefly overviewed theories ranging from Fruedian psychoanalytic theory to biologically-based theories. They wrote:
Psychoanalytically self-injurious behaviour has been linked to castration and explained as a process of failure to resolve oedipal complex, repressed impulses, self punishment, focal suicide and aggression turned inwards especially in cases of depression. [Other authors] have postulated interpersonal loss preceding self-injurious behaviour and linked it to rejection sensitivity…Biologically serotonergic depletion preceding self-mutilation has been linked to aggression and depression…Some authors have claimed strong moral, religious and delusional component”
A recent literature review by Dr. Alexander Fan in the journal Psychiatry reported that the vast majority of auto-enucleation cases suffer from psychotic illness (particularly schizophrenia) although other medical and/or psychiatric conditions associated with auto-enucleation include obsessive-compulsive neuroses, severe depression, post-traumatic stress disorders, drug-induced psychoses, bipolar mania. There are also case studies where auto-enucleation has been linked with structural brain lesions, Down Syndrome, epilepsy, neurosyphilis, and Lesch-Nyhan syndrome (juvenile gout). These are similar to other forms of extreme self-mutilation. For instance, self-mutilation in schizophrenia in response to auditory hallucinations has often been described as Van Gogh Syndrome (in reference to the painter’s self-excision of his own left ear)
Other reviews of the psychiatric literature have reported that those who remove their own eyes commonly have delusions (typically sexual and/or religious) and that when asked about motivations for self-harming include reasons such as guilt, atonement, sin, evil, etc. Although some authors have noted that enucleators with religious beliefs are often Christian, other case studies have made reference to other religious faiths (e.g., Muslims). Finally, another paper by Favazza in Hospital and Community Psychiatry concluded that:
“Males in a first episode of a schizophrenic illness that is characterized by delusions associated with a body part or religious delusions are at the greatest risk for MSM [major self-mutilation]. However, MSM of this severity is so rare that it cannot be predicted accurately unless there has been a previous attempt at self-injury or the patient has spoken about wanting to remove or injure an organ. Threatened ocular mutilation deserves special mention because it may occur in a hospital setting, and the case histories suggest that one-to-one nursing is not always be sufficient to prevent enucleation”.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Berguaa, A., Sperling, W. & Kuchlea M. (2002). Self-enucleation in drug-related psychosis. Ophthalmologica, 216, 269-271.
Eric, J.C., Nevitt, M.P., Hodge, D. & Ballard, D.J. (1984). Incidence of enucleation in a defined population. American Journal of Ophthalmology, 113, 138-44.
Fan, A.H. (2007). Autoenucleation: A case report and literature review. Psychiatry, October, 60-62.
Favazza, Armando (1998) ‘Introduction’, in Marilee Strong A Bright Red Scream: Self-mutilation and the Language of Pain. New York: Viking.
Favazza, A. & Rosenthal R. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44, 134-140.
Field, H. & Waldfogel, S. (1995). Severe ocular self-injury. General Hospital Psychiatry, 17, 224-227.
Gamulescu, M.A., Serguhn, S., Aigner, J.M., Lohmann, C.P., & Roider J. (2001). Enucleation as a form of self-aggression, two case reports and review of the literature. Klin Monatsbl Augenheilkd, 218, 451-454.
Ghaffari-Nejad, A., Kerdegari, M., & Reihani-Kermani, H. (2007) Self-mutilation of the nose in a schizophrenic patient with Cotard Syndrome. Archives of Iranian Medicine, 10, 540-542.
Gottrau, P., Holbach, L.M. & Nauman, G.O. (1994). Clinicopathological review of 1,146 enucleations (1980-90). British Journal of Ophthalmology, 78, 260-5.
Jeffreys, S. (2000). ‘Body art’ and social status: Cutting, tattooing and piercing from a feminist perspective Feminism and Psychology, 10, 409-429.
Krauss, H., Yee, R. & Foos, R. (1994). Autoenucleation. Survey of Ophthalmology, 29, 179-87.
MacLean, C. & Robertson, B.M. (1976). Self enucleation and psychosis. Archives of General Psychiatry, 33, 242-249.
Patil, B. & James, N. (2004). Bilateral self-enucleation of eyes. Eye, 18, 431-432.
Patton N. (2004). Self-inflicted eye injuries: A review. Eye, 18, 867-872.
Rao, K.N. & Begum, S. (1996) Self enucleation in depression; A case report. Indian Journal of Psychiatry, 38, 267-70
Witherspoon, D., Feist, F., Morris, R. & Feist, R. (1989). Ocular self-mutilation. Annals of Ophthalmology, 21, 255-259.
Lovestruck: A brief look at de Clérambault’s Syndrome
In previous blogs I have looked at both love addiction and obsessional love. Since writing my blog on obsessional love and noting that it is also known as erotomania, I have received a couple of emails from clinicians saying that obsessional love is not necessarily erotomania by definition. The problem with the wider area of obsessions, compulsions and addiction more generally is that academics and clinicians have different definitions of what it is to be obsessed or addicted to something.
In clinical circles, erotomania is known as de Clérambault’s syndrome (DCS), and was named after a paper published in 1921 (Les Psychoses Passionelles) by the French psychiatrist Gaëtan de Clérambault. Those with DCS typically have a delusional belief that another person (typically someone famous, high status and/or a stranger) is in love with them. Some of the scientific literature suggests that DCS sufferers may have experienced loss of people that were emotionally close to them, and that therefore they may feel emotionally and psychologically safer by attaching themselves to people who are unattainable. Such actions prevent any further losses. In a 1983 issue of Psychological Medicine, Dr. P. Taylor and colleagues described the main components of DCS:
- The presence of a delusion that the individual (usually described as a female) is loved by a specific man;
- The woman has had little or no contact with the man;
- The man is unattainable in some way, because he is already married or because he has no personal interest in her;
- The man is perceived as watching over, protecting or following the woman;
- Despite the erotic delusion, the woman remains chaste.
One of the reasons I am personally interested in DCS is that back in the early 1990s, my then girlfriend (who was – and still is – a clinical psychologist) was the object of affection by a DCS sufferer. The man who fell in love with my girlfriend was slightly brain damaged following a bad motorcycling accident. The accident had also left him paralyzed and had to use a wheelchair. As part of her job, my girlfriend worked with the charity Headway (a brain injury association), and it was when she was caring for this head injured and paralyzed man that he fell in love with her and believed that the feelings were reciprocal. The condition was so intense that he even booked a wedding date, sent out wedding invitations, and told all his family and friends that he was marrying my girlfriend. I even started to question my girlfriend’s fidelity because I couldn’t comprehend that someone could organize a whole wedding if nothing had ever happened between them. (Even though I was a psychologist when this happened I had never come across DCS).
The research literature on DCS suggests that the delusional behaviour is usually part of psychotic behaviour (typically schizophrenia, bipolar disorder, or borderline personality disorder) and can therefore be treated using atypical anti-psychotics (however, most DCS sufferers do not ask for help or seek treatment as they don’t believe they are doing anything wrong). According to the Wikipedia entry on DCS (and based on a paper published in a 1998 issue of the Journal of Neuropsychiatry and Clinical Neuroscience by Dr. C. Anderson and colleagues):
“During an erotomanic episode, the patient believes that a ‘secret admirer’ is declaring his or her affection to the patient, often by special glances, signals, telepathy, or messages through the media. Usually the patient then returns the perceived affection by means of letters, phone calls, gifts, and visits to the unwitting recipient. Even though these advances are unexpected and unwanted, any denial of affection by the object of this delusional love is dismissed by the patient as a ploy to conceal the forbidden love from the rest of the world”.
In a 2002 issue of the journal History of Psychiatry, Dr. German Berrios and Dr. N. Kennedy describe four convergences in the history of erotomania.
- Convergence 1: From classical times to the early eighteenth century, erotomania was viewed as a ‘general disease caused by unrequited love’.
- Convergence 2: During the nineteenth century, erotomania was viewed as a disease of ‘excessive physical love (nymphomania)’
- Convergence 3: During the twentieth century, erotomania was viewed as a form of ‘mental disorder’
- Convergence 4: Currently, erotomania is viewed as a ‘delusional belief of being loved by someone else’.
Berrios and Kennedy also note that there are differences between Anglo-Saxon and French views surrounding the meaning or coherence of “the much-abused English eponym ‘de Clérambault syndrome’. Erotomania is a construct, a mirror reflecting Western views on spiritual and physical love, sex, and gender inequality and abuse. On account of this, it is unlikely that there will ever be a final, ‘scientific’ definition rendering erotomania into a ‘natural kind’ and making it susceptible to brain localization and biological treatment”.
Empirical research suggests that women are more likely than men to suffer from DCS, and that DCS sufferers tend to have social and intimacy difficulties, and are therefore typically loners. Developmentally, they are likely to have a poor sense of self and may have suffered abuse during childhood and/or adolescence. Much of the published theorizing about erotomania is from a psychodynamic perspective or genetic/neurochemical presispositions. I’m far more eclectic in my approach to understanding human behaviour and believe that environmental, psychological, pharmacological and physiological factors most likely trigger a predisposed person into developing DCS. It’s also been speculated that learning through the media (television, radio, books, etc.) has influenced the development of DCS.
Dr. Louis Schlesinger in his 2004 book Sexual Murder: Catathymic and Compulsive Homicides writes about DCS sufferers in relation to possible stalking behaviour. He notes that: “some stalkers are unable to give up a prior intimate relationship (Zona, Sharma, and Lane, 1993). Some develop delusional beliefs about the target (Goldstein, 1987), while others develop strong obsessional thoughts about virtual strangers (Spitzberg and Cupach, 1994). Meloy (1992) and Kienlen (1998) believe that a disturbance of attachment begins in the offender’s early childhood and stalking starts when some type of loss in adulthood resurrects these early conflicts”
In some individuals, DCS can remain with the person for a long time. For instance, Dr. Harold Jordan and colleagues published a paper in a 2006 issue of the Journal of the National Medical Association. They reviewed two cases of DCS that they had followed for over 30 years “making these some of the longest, single-case longitudinal studies yet reported”. They noted that DCS remains a “ubiquitous nosological psychiatric entity with uncertain prognosis”. De Clerambault’s original paper presented the case of a woman whose chronic, erotic delusion remained with her for 37 years, and the cases reported by Dr. Jordan and his colleagues also demonstrated that the delusion can remain unchanged for decades. I have yet to come across any research that estimates the prevalence of DCS among the general population but given most published papers are clinical case reports, it suggests the disorder is relatively rare.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Anderson CA, Camp J, Filley CM (1998). Erotomania after aneurismal subarachnoid hemorrhage: Case report and literature review. Journal of Neuropsychiatry and Clinical Neuroscience, 10, 330-337.
Berrios G.E. & Kennedy, N. (2002). Erotomania: a conceptual history. History of Psychiatry, 13, 381-400.
Jordan, H.W., Lockert, E.W., Johnson-Warren, M., Cabell, C., Cooke, T., Greer, W. & Howe, G. (2006). Erotomania revisited: Thirty-four years later. Journal of the National Medical Association, 98, 487-793.
Schlesinger, L.B. (2004). Sexual murder: Catathymic and compulsive homicides. London: CRC Press.
Taylor, P., Mahendra, B. & Gunn J. (1983). Erotomania in males. Psychological Medicine, 13, 645-650.
Zona, M., Sharma, K., and Lane, J. (1993). A comparative study of erotomania and obsessional subjects in a forensic sample. Journal of Forensic Sciences, 38, 894–903.