“I ink, therefore I am”: A brief look at ‘tattoo addiction’

“When I first told people back in 2016 that I was getting my first tattoo, the most common response I got from those who were already inked themselves was ‘You’re going to get addicted to getting tattoos’. I found this notion a little ridiculous – I was nervous enough just getting a small one on my ankle. I couldn’t imagine getting hooked on something that was not only expensive, but painful and permanent. Fast forward to 2019, and I’ve since gotten two more tattoos, each one progressively larger and more detailed, and I’m already planning my fourth, fifth, sixth, etc. As I was warned, I have indeed gotten hooked. For me, it’s both because I love how it makes me feel about my body, and because I’ve gotten to discover a new form of expression in my mid-30s. According to a 2018 report from Statista, roughly 46 percent of Americans have at least one tattoo, and 30 percent of these people have two or three –19 percent have up to four or five. Clearly, other people love getting inked just as much as I do. But while tattoos can be fun to have, are they actually addictive?

This opening quote is by Amy Semigran, a journalist who interviewed me earlier this year for an article she was writing on addictions to tattoos for the online magazine Mic (‘Are tattoos really addictive? There’s a reason you keep coming back for more’). Regular readers of my blog will be aware that I’ve written various articles on the psychology of tattoos over the years including articles on stigmatophilia (sexual arousal from a partner who is marked or scarred in some way, which can also include body tattoos), the use of extreme tattooing in films, a look at the TV programme ‘My Tattoo Addiction’, and an article on whether having tattoos makes women more sexually attractive.

In my interview, I told Semigran that in order for a person’s behaviour to be deemed an addiction, it needs to meet my six specific criteria: salience (where tattooing becomes the most important thing in a person’s life), mood modification (e.g., the euphoric feelings that accompany tattooing), tolerance (the gradual build-up of tattooing with the individual spending more and more time engaged in tattooing), withdrawal symptoms (negative psychological and/or physical consequences as a result of not being able to get tattooed such as extreme moodiness or irritability), conflict (tattooing compromising other areas of the individual’s life such as personal relationships and education/occupation), and relapse (returning to tattooing after a period of abstinence). Therefore, I told Semigran that tattooing does not meet my criteria for addiction. I also added that while many behaviours can become impulsive, addiction relies on constant rewards or reinforcement. Alcoholics, gambling addicts, or drug addicts feed their habits with frequent rewarding experiences (at least in the short-term) but even the most heavily tattooed people are not engaging in the behaviour regularly.

However, it is feasible that tattooing could be a behaviour that results in constant preoccupation (e.g., constantly thinking about getting the next tattoo, looking at tattoo designs, reading tattooing magazines, talking with other heavily tattooed individuals and sharing experiences, working as a tattooist, etc.). However, constantly being preoccupied by tattooing is (in itself) not a problem, unless of course it starts to cause serious conflict with other day-to-day activities. Semigran also interviewed Dr. Daniel Selling (a psychologist at Williamsburg Therapy Group in New York) for her article. He was quoted as saying:

“The word addiction in the context of tattoos is misused…while you can’t have a tattoo addiction, per se, it can be a dependence where you feel some elements of need and withdrawal…and perhaps spend too much time or money getting work…Being tattooed can also lead to an adrenaline rush of sorts. It’s the body tolerating annoyance and pain coupled with excitement and change”.

I agree that some people can spend too much time or money or spend money they don’t have on getting tattoos, but this is not addiction (and I would also argue that it is not dependence either). For many people, getting tattoos might be more of a passion than a problem, and there is nothing wrong with being passionate about what you do. I am passionate about work and some people describe me as being addicted to work or of being a ‘workaholic’ but given there are almost no negative consequences of me working hard and loving my job, it certainly can’t be viewed as an addiction.

As Semigran pointed out in her article, for many people, their passion and interest in tattooing is something that enhances their lives rather than interferes with it (this is exactly the same as my assertion – published in a 2005 issue of the Journal of Substance Use) that healthy excessive enthusiasms add to life whereas addictions take away from it. Semigran interviewed Lisa Orth, a Los Angeles-based tattoo artist Lisa Orth who has around 100 tattoos). She said:

“It’s an incredible feeling to be able to permanently customize yourself with artwork. [The] feeling of self-expression can be an empowering experience…It’s one of the main reasons [my] clients come back again and again. Tattooing can be a way of engaging with, and taking possession of, one’s body in an active way…[It] can allow people to define themselves visually in a way that forces the observer to see a person as they most authentically see themselves. That’s a big draw (so to speak) for those who repeatedly get inked…Getting tattooed is one of the remaining rituals in our culture that are physical, mental and emotional challenges, where you come out transformed on the other side”.

Again, this explanation has nothing to do with addiction and everything to do with self-identity and passion. Many addiction psychologists, would also add that if he behaviour causes harm or injury to the individual, it may also be a sign or symptom of possible addiction. However, Semigran quoted American psychologist, Dr. Tracy Alderman from an article she wrote for Psychology Today examining the extent to which tattooing and body piercings can be classed as self-harm.

“[E]njoying a rush is different than participating in self-harm. Since tattooing is a needle penetrating skin, that can potentially feed someone’s desire to feel pain or change their appearance due to unhappiness with themselves…Once in a while there will be cases in which piercing and/or tattoos do fit the definition of self-injury. But overwhelmingly,self-injury is a distinct behavior, in definition, method and purpose, from tattooing and piercing”.

I read Dr. Alderman’s article and her views mirror my own when it comes to the psychology of tattooing:

“[A] main issue separating self-injurious acts from tattoos and piercings is that of pride. Most people who get tattooed and/or pierced are proud of their new decorations. They want to show others their ink, their studs, their plugs. They want to tell the story of the pain, the fear, the experience. In contrast, those who hurt themselves generally don’t tell anyone about it. Self-injurers go to great lengths to cover and disguise their wounds and scars. Self-injurers are not proud of their new decorations”.

Semigran also quoted Dr. Suzanne Phillips who recently wrote an article for PsychCentral entitled ‘Tattoos after trauma-do they have healing potential’. Dr. Phillips notes:

“[A tattoo being used] to register a traumatic event is a powerful re-doing…It starts at the body’s barrier of protection, the skin, and uses it as a canvas to bear witness, express, release and unlock the viscerally felt impact of trauma”.

There’s no doubt that tattooing has become part of mainstream culture over the past two decades and there are a number of scholars who claim in the scientific literature that getting tattoos can be potentially addictive (such as Dr. Ivan Sosin; Dr. Allyna Murray and Dr. Tanya Tompkins; see ‘Further Reading’ below) but based on my own addiction criteria I remain to be convinced. However, whenever I think about the psychology of tattooing, I am always reminded of the saying: “Tattoos are like potato chips … you can’t have just one”.

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

Further reading

Alderman, T. (2009). Tattoos and piercings: Self-injury? Psychology Today, December 10. Located at: https://www.psychologytoday.com/nz/blog/the-scarred-soul/200912/tattoos-and-piercings-self-injury?amp

Griffiths, M.D. (1996). Behavioural addictions: An issue for everybody? Journal of Workplace Learning, 8(3), 19-25.

Griffiths, M.D.  (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Kovacsik, R., Griffiths, M.D., Pontes, H., Soós, I., de la Vega, R., Ruíz-Barquín, R., Demetrovics, Z., & Szabo, A. (2019). The role of passion in exercise addiction, exercise volume, and exercise intensity in long-term exercisers. International Journal of Mental Health and Addiction, https://doi.org/10.1007/s11469-018-9880-1

Murray, A. M., & Tompkins, T. L. (2013). Tattoos as a behavioral addiction. Science and Social Sciences, Submission 26. Located at: https://digitalcommons.linfield.edu/studsymp_sci/2013/all/26

Phillips, S. (2019). Tattoos after trauma-do they have healing potential? PsychCentral, March 27. Located at: https://blogs.psychcentral.com/healing-together/2012/12/tattoos-after-trauma-do-they-have-healing-potential/

Semigran, A. (2019). Are tattoos really addictive? There’s a reason you keep coming back for more. Mic, July 3. Located at: https://www.mic.com/p/are-tattoos-really-addictive-theres-a-reason-you-keep-coming-back-for-more-18166085

Sosin, I. (2014). EPA-0786-Tattoo as a subculture and new form of substantional addiction: The problem identification. European Psychiatry, 29, Supplement 1, 1.

Szabo, A., Griffiths, M.D., Demetrovics, Z., de la Vega, R., Ruíz-Barquín, R., Soós, I. &Kovacsik, R. (2019). Obsessive and harmonious passion in physically active Spanish and Hungarian men and women: A brief report on cultural and gender differences. International Journal of Psychology, 54, 598-603.

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.

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

No pain, no gain: A brief look at religious self-flagellation

In previous blogs, I have looked at various aspects of sexually masochistic behaviour. However, some masochistic behaviours have religious (rather than sexual) motivations. Many people’s first awareness of religious masochism might have been Paul Bettany’s portrayal of the self-flagellating albino Catholic monk (Silas) in The Da Vinci Code film (based on Dan Brown’s bestseller). Silas was a member of Opus Dei, a branch of the Catholic Church that has a reputation of being highly secretive. The inflicting of pain upon oneself by Opus Dei adherents is one of a number of self-initiated behaviours involved in the practice of mortification. According to the Wikipedia entry on Opus Dei:

“Mortification the voluntary offering up of discomfort or pain to God; this includes fasting, or in some circumstances self-inflicted pain such as self-flagellation. Mortification has a long history in many world religions, including the Catholic Church. It has been endorsed by Popes as a way of following Christ, who died in a bloody crucifixion and who gave this advice: ‘let him deny himself, take up his cross daily and follow me’ (Lk 9:23). Supporters say that opposition to mortification is rooted in having lost (1) the ‘sense of the enormity of sin’ or offense against God, and the consequent penance, both interior and exterior, (2) the notions of ‘wounded human nature’ and of concupiscence or inclination to sin, and thus the need for ‘spiritual battle’, and (3) a spirit of sacrifice for love and ‘supernatural ends’, and not only for physical enhancement. Critics claim that such practices that inflict pain are counterproductive given modern advances. As a spirituality for ordinary people, Opus Dei focuses on performing sacrifices pertaining to normal duties and to its emphasis on charity and cheerfulness. Additionally, Opus Dei celibate members practise ‘corporal mortifications’ such as sleeping without a pillow or sleeping on the floor, fasting or remaining silent for certain hours during the day”.

According to a BBC news story on why Catholics engage in self-flagellation the article asserted that such behaviour is acted out for symbolic purposes during penitential processions (typically in Mediterranean countries during Lent – to remind devout believers that Jesus was whipped before he was crucified). It was even alleged that Pope John Paul II (who was made a saint by the Catholic church earlier this week) possibly engaged in self-flagellation. Other devotees in other countries (such as the Philippines, and some South American countries) participate in ‘Passion Plays’ where people will engage in painful practices that draw blood.

Last year, I was interviewed about religious self-harm as part of the television series Forbidden – a program on which I was the resident psychologist. The documentary focused on a man from Brazil (Adriano Da Silva) who was totally devoted to God. However, weekly praying wasn’t enough to prove their dedication and faith. As the production notes reported:

“They are hardcore penitents who feel to get closer to God you need to endure the literal suffering of Jesus Christ – you need to cut yourself with razor blades…[Adriano is a] very spiritual man, he prays many times a day, reads his bible, and attends church. However, Adriano is about to take his faith to a completely new level. He’s about to undergo the biggest change of his young life. He is about to become the leader of a group of hardcore and extreme religious penitents, The Brotherhood of Canindezinho. He’s been in training for this moment for a long time, self inflicted punishment is what being a penitent is all about. He’s gone without food for days, walked for miles and miles in the desert to get closer to God. But before he can become leader he must do something he’s never done before. He must make a leap of faith he’s observed for years but always been too frightened to go ahead with. On the biggest day of their religious calendar, Adriano will self-flagellate for the first time, cutting himself with blades until the blood runs down his back and drips to the street below”.

Adriano was taking over as the leader of the ‘Brotherhood of Canindezinho’ (Chico Varela). In fact, Chico was the person that taught Adriano how to attach the razor blades to the string and mentored him through the process of how to psychologically prepare himself for the self-inflicted harm he was about to undertake. His first self-flagellation took place in front of his fellow penitents in the resurrection ritual – the largest religious event of the Brotherhood calendar:

“This is a mass self-flagellations event where The Brotherhood of Canindezinho join up with a neighbouring group of penitents – The Brotherhood of Varzea Alegre [led by Antonio Viera]. They will meet up in the local town square and then drag a giant cross through the town till they get to the cemetery. It is here that they will then begin to cut themselves. Chico will be performing a vital task during the event. He’ll be monitoring Adriano and the other penitents to ensure their safety so that they don’t lose too much blood. ‘When consumed with the passion of the Christ it is easy to lose yourself in the pain, your own safety becomes secondary, this is why it’s important for us to look after our fellow Brothers’. The sun goes down over the cemetery and still the penitents continue to lash themselves…As blood drips down, the penitents report feeling no pain or withstanding the pain for a higher purpose: ‘Jesus gives me the power’, says a penitent”

For the Brotherhood of Canindezinho, the purpose of self-flagellation ritual is to (i) purify their soul and redeem them on unholy acts, such as women and alcohol, as a step to be closer to God; and (ii) thank God for granting them graces they previously petitioned for (e.g., somebody recovering from a serious illness or somebody that got themselves out of a serious financial situation). The television production notes also reported that:

“The selected penitents take their shirts off, at once, and go at it. They self-flagellate for 20 minutes, approximately, hitting their backs with sharp razor blades attached to the end of a string relentlessly. Children, from age 10 up can also participate in the ritual. Women, on the contrary cannot, since they are already believed to be ‘sufferers’. Once the self-flagellating is over, the penitents put their shirts back on – as if nothing just happened, and go home to cleanse the wounds”.

Other articles on religious flagellation (such as one by Geoffrey Abbott in the online version of Encyclopaedia Britannica) also claim that self-flagellation is used as a way to drive out evil spirits, to purify, and “as an incorporation of the animal power residing in the whip” but that none of these reasons encompass the whole range of the religious custom. In fact, Abbott claimed:

“In antiquity and among prehistoric cultures, ceremonial whippings were performed in rites of initiation, purification, and fertility, which often included other forms of physical suffering. Floggings and mutilations were sometimes self-inflicted. Beatings inflicted by masked impersonators of gods or ancestors figured in many Native American initiations. In the ancient Mediterranean, ritual floggings were practiced by the Spartans, and Roman heretics were whipped with thongs of oxtail, leather, or parchment strips, some being weighted with lead”.

During my research for this article, I came across numerous academic papers that noted religious and cultural factors may influence self-harm but none of these papers indicated how prevalent religious self-harm was (but I am assuming it was rare given the lack of statistics). Given that we know little about the incidence or prevalence of such behaviour, this is certainly an area worthy of further academic research.

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

Further reading

Abbott, G. (2013). Flagellation. Encyclopaedia Britannica Online, June 6. Located at: http://www.britannica.com/EBchecked/topic/209255/flagellation

Babiker, G. & Arnold, L. (1997). The Language of Injury: Comprehending Self-Mutilation. Leicester: British Psychological Society Books

BBC News (2009). Why do some Catholics self-flagellate? November 24. Located at: http://news.bbc.co.uk/1/hi/magazine/8375174.stm

Walsh, B.W. & Rosen, P.M. (1988) Self-Mutilation: Theory, Research and Treatment. New York:Guilford Press.

Wikipedia (2014). Mortification of the flesh. Located at: http://en.wikipedia.org/wiki/Mortification_of_the_flesh

Wikipedia (2014). Opus Dei. Located at: http://en.wikipedia.org/wiki/Opus_Dei

Die another day: A brief look at ‘addiction to near death’

In previous blogs I have examined both people’s fascination with death and human near death experiences (NDEs). Another aspect to NDEs that I didn’t mention in those articles was the idea of people being “addicted” to NDEs. Arguably, most people’s perceptions of ‘near death addiction’ are probably based on the 1990 US film Flatliners. In that film, a group of five medical students (played by Keifer Sutherland, Kevin Bacon, Julia Roberts, Oliver Platt and William Baldwin) attempt to examine whether there is anything beyond death by carrying out experiments into NDEs. Keifer Sutherland’s character (Nelson) is continually made to experience clinical death (i.e., flatlining with no heartbeat) before being brought back to life by his classmates.

This Hollywood portrayal of possible ‘near death addiction’ bears little resemblance to the academic literature – most of which has been written from a psychodynamic perspective – and relates more to continual self-destructive experiences (usually by adolescents or young adults). The concept of ‘addiction to near death’ (ATND) originates from the writings of Dr. Betty Joseph, a distinguished psychoanalytic clinician often lauded as “the psychoanalysts’ psychoanalyst” and known for her work with highly resistant ‘difficult to treat’ patients. Dr. Joseph first wrote about the ‘addiction to near death’ concept in a 1982 issue of the International Journal of Psychoanalysis. This form of masochistic pathology was a concept that she found useful when working with psychologically dysfunctional adolescents. As Dr. Janet Shaw noted in a more recent 2012 paper on ATND in the Journal of Child Psychotherapy:

“At [the adolescent] stage of development, there is a tendency for adolescents who are troubled to turn to destructive or self-destructive behaviour, suicidal ideation, self-harm, self-starvation and inappropriate sexual behaviour. This is often profoundly shocking and alarming to others, especially if the young person finds the impact on others pleasurable. [Betty] Joseph described a patient addicted to near death as being caught up in a wish to gain pleasure by destroying both himself and the analytic relationship…[She] described masochistic destruction of the self taking place with libidinal satisfaction, despite much concomitant pain. The masochistic position is deeply addictive and this way of using pain for the purposes of pleasure becomes habitual. She summed this up as, ‘the sheer unequalled sexual delight of the grim masochism’ and described the awful pleasure that is achieved in this way”.

However, as Dr. Shaw rightly points out, not all types of destructive and self-destructive behaviour fall into such a category. In her 1982 paper, Dr. Joseph outlined case studies she had treated psychoanalytically from her private practice. Here, she described the masochistic dynamics of her patients, and how hard it was for them to alter these dynamics and get better. She noted that one of the key aspects of the dynamics she described was that her patients derived immense libidinal satisfaction from engaging in destructive near-death behaviours. More specifically, she wrote:

“There is a very malignant type of self-destructiveness, which we see in a small group of our patients, and which is, I think, in the nature of an addiction – an addiction to near-death. It dominates these patients’ lives; for long periods it dominates the way they bring material to the analysis and the type of relationship they establish with the analyst; it dominates their internal relationships, their so-called thinking, and the way they communicate with themselves. It is not a drive towards a Nirvana type of peace or relief from problems, and it has to be sharply differentiated from this. The picture that these patients present is, I am sure, a familiar one – in their external lives these patients get more and more absorbed into hopelessness and involved in activities that seem destined to destroy them physically as well as mentally, for example, considerable over-working, almost no sleep, avoiding eating properly or secretly over-eating if the need is to lose weight”.

In a 2006 issue of Psychanalytic Psychology, Dr. William Gottdeiner also noted that the ATND is such a strong motive that successful treatment of such individuals is unusually difficult. However, Dr. Gottdeiner asserted that one of the severe weaknesses of Joseph’s writings is that she failed to provide in-depth clinical examples of anyone who had engaged in potentially deadly activities. This, Gottdeiner contended, threatened the validity of the ATND construct. Despite such inherent weaknesses, Gottdeiner still believed the ATND construct had strong face validity (i.e., “there are people who seem to repeatedly engage in potentially lethal behavior, making the ATND construct plausible”). Consequently, Gottdeiner tested the construct validity of ATND on females with substance use disorders (SUDs). His argument was that:

“If individuals who are diagnosed with an SUD are successfully treated and they continue to engage in potentially deleterious behavior, then that finding would support the notion that the individual has an addiction to near-death experiences, and that the individual’s substance abuse was a comorbid disorder”.

Gottdeiner’s paper attempted to validate the ATND construct via secondary analysis “of data from a treatment outcome study of individuals who were in residential therapeutic community treatment for SUDs and who received simultaneous safe-sex education during treatment”. His study findings showed that despite safe-sex education and sexual activity in the therapeutic communities being prohibited, that some of the participants still engaged in risky sexual behaviour (irrespective of whether their sexual partners were HIV-positive or not). Gottdeiner argued that these findings tentatively supported the ATND construct. However, Gottdeiner was the first to admit that his study had inherent weaknesses. As he noted:

“The limitations were: data were from retrospective self-reports [and] contained no baseline measures of sexual activity, safe-sex knowledge, condom use, HIV status; it had no male participants, no specific questions about near-death behavior, nor whether alternative safe-sex activities were practice…The limitations of [the] study are considerable, and some might even argue that the connection between the ATND construct and the data presented herein is too much of a stretch to be scientifically useful…Obviously, stronger data would lead to stronger conclusions. Despite the limitations of this study, the findings should motivate clinicians to more seriously consider the existence of an addiction to near-death in their clients”.

More recently, Dr. Janet Shaw examined the ATND construct through the description and evaluation of an in-depth case study account of an adolescent female (‘Susan’). Her paper explored “the way in which pleasure, which is sadistic and masochistic in nature, is associated with cruelty towards the self or others in adolescence”. Dr. Shaw wrote that it felt as if Susan’s main aim was to torment her. As Shaw reported:

“In addition to suicide threats, similar to those she made in the assessment, she made constant reference to systematically starving herself. She was painfully thin, although not actually anorexic and she was poisoning herself by repeatedly taking paracetamol. Susan’s threats to self-harm had a deeply disturbing quality and she clearly enjoyed making them. There was a wish to punish me, as well as herself, through her phantasised attacks…The case material is an example of an adolescent girl with ‘an addiction to near death’ constituting a dominant way of relating to others. Her relentless and manipulative references to self-harm, suicide and dangerous behaviour at various stages of the work were designed to shock and alarm…Susan’s self-destructive behaviour was also continuing in relation to her self- starvation. She said she took laxatives in an attempt to lose more weight. She was becoming dangerously thin and three years into her psychotherapy an appointment with the referring psychiatrist resulted in a diagnosis of anorexia nervosa”.

This quote doesn’t do justice to the very detailed account that Dr. Shaw provided in her lengthy paper. However, her written account is heartfelt and brutally honest. Shaw concludes that the compelling power of addiction overviewed in Susan’s case mustn’t be underestimated. As she notes:

“The narcissistic idealisation of sadistic and masochistic behaviour offers some protection from fear and terror for the patient, but the consequence is to severely limit capacity for thought and imagination, and to restrict awareness. ‘Addition to near death’ forms a small but significant component of the clinical casework of a child and adolescent psychotherapist: it is hoped that Susan’s case material serves to illuminate the phenomenon further and its technical challenges”.

Whether the clinical case of Susan provides any more evidence for validation for Joseph’s ATND construct than the more empirical work of Gottdeiner is debatable. However, this is certainly a fascinating – if somewhat harrowing – area of clinical and academic work that certainly warrants further empirical examination.

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

Further reading

Gottdiener, W.H. (2006). A preliminary test of the Addiction-to-Near-Death construct. Psychoanalytic Psychology, 23, 661-666.

Joseph, B. (1982). Addiction to near death. International Journal of Psychoanalysis, 449-456.

Joseph, B. (1988). Addiction to near death. In Bott Spillius, E. (Ed.) Melanie Klein Today (pp.311-323). London and New York: Routledge.

Ryle, A. (1993). Addiction to the death instinct? A critical review of Joseph’s paper ‘Addiction to near death’. British Journal of Psychotherapy, 10, 88–92.

Shaw, J. (2012). Addiction to near death in adolescence. Journal of Child Psychotherapy, 38, 111-129.