I have just come back from a two-week holiday in Portugal and managed to catch up with reading a lot of non-academic books. Two of the books I took with me were Paul Trynka’s biography of Iggy Pop (Open Up and Bleed ) and Brett Callwood’s biography of The Stooges, the band in which Iggy Pop first made his name (The Stooges: A Journey Through the Michigan Underworld ). Just before I left to go on holiday I also read Dave Thompson’s book Your Pretty Face is Going to Hell: The Dangerous Glitter of David Bowie, Iggy Pop, and Lou Reed (2009). This engrossing reading has been accompanied by me listening to The Stooges almost non-stop for the last month – not just their five studio albums (The Stooges , Fun House , Raw Power , The Weirdness , and Ready To Die ) but loads of official and non-official bootlegs from the 1970-1974 period. In short, it’s my latest music obsession.
Although I say it myself, I have been a bit of an Iggy Pop aficionado for many years. It was through my musical appreciation of both David Bowie and Lou Reed that I found myself enthralled by the music of Iggy Pop. Back in my early 20s, I bought three Iggy Pop albums purely because they were produced by David Bowie (The Idiot , Lust For Life , and Blah Blah Blah ). Thankfully, the albums were great and over time I acquired every studio LP that Iggy has released as a solo artist (and a lot more aside – I hate to think how much money I have spent on the three artists and their respective bands over the years). Unusually, I didn’t get into The Stooges until around 2007 after reading an in-depth article about them in Mojo magazine. Since then I’ve added them to my list of musical obsessions where I have to own every last note they have ever recorded (official and unofficial). When it comes to music I am all-or-nothing. Maybe I’m not that far removed from my musical heroes in that sense. I’m sure my partner would disagree. She says I’m no different to a trainspotter who ticks off lists of numbers.
One thing that connects Pop, Reed and Bowie (in addition to the fact they are all talented egotistical songwriters and performers who got to know each other well in the early 1970s) is their addictions to various drugs (heroin in the case of Pop and Reed, and cocaine in the case of Bowie – although they’ve all had other addictions such as Iggy’s dependence on Quaaludes). This is perhaps not altogether unexpected. As I noted in one of my previous blogs on whether celebrities are more prone to addiction than the general public, I wrote:
“Firstly, when I think about celebrities that have ‘gone off the rails’ and admitted to having addiction problems (Charlie Sheen, Robert Downey Jr, Alec Baldwin) and those that have died from their addiction (Whitney Houston, Jim Morrison, Amy Winehouse) I would argue that these types of high profile celebrity have the financial means to afford a drug habit like cocaine or heroin. For many in the entertainment business such as being the lead singer in a famous rock band, taking drugs may also be viewed as one of the defining behaviours of the stereotypical ‘rock ‘n’ roll’ lifestyle. In short, it’s almost expected”.
Nowhere is this more exemplified than by Iggy Pop. Not only would Iggy take almost every known drug to excess, it seemed to carry over into every part of his lifestyle. For instance, reading about Iggy’s sexual exploits, there appears to be a lot of evidence that he may have also been addicted to sex (although that’s speculation on my part with the only evidence I have is all the alleged stories in the various biographies of him). Another thing that amazes me about Iggy Pop was that he decided to give up taking drugs in the autumn of 1983 and pretty much stuck to it (again mirroring Lou Reed who also decided to clean up his act and go cold turkey on willpower alone). Spontaneous remission after very heavy drug addictions is rare but Iggy appears to have done it. Maybe Iggy gave up his negative addictions for a more positive addiction – in his case playing live. David Bowie went as far as to say that playing live was an “obsessive” for Iggy. As noted in Paul Trynka’s biography:
“[His touring] was simultaneously impressive and inexplicable. David Bowie used the word’ obsessive’ about Iggy’s compulsion to tour – but there was an internal logic. Jim knew he’d made his best music in the first ten years of his career, and he also believed he’d blown it…but he knew his own excesses or simple lack of psychic stamina were a key reason why the Stooges crashed and burned. Now he had to still prove his stamina, to make up for those weaknesses of three decades ago”.
Iggy Pop is (of course) a stage name. Iggy was born James Newell Osterberg (April 21, 1947). The ‘Iggy’ moniker came from one of the early bands he drummed in (The Iguanas). I mention this because another facet of Iggy Pop’s life that I find psychologically interesting is the many references to ‘Iggy Pop’ being a character created by Jim Osterberg (in much the same way that Bowie created the persona ‘Ziggy Stardust’ – ironically a character that many say is at least partly modeled on Iggy Pop!). Many people that have got to know Jim Osterberg describe him as intelligent, witty, talkative, well read, and excellent social company. Many people that have been in the company of Iggy Pop describe him as sex-crazed, hedonistic, outrageous, a party animal, and a junkie (at least from the late 1960s to the early to mid-1990s). It’s almost as if a real living character was created in which Jim Osterberg could live out an alternative life that he could never do as the person he had become growing up. Iggy Pop became a persona that Jim Osterberg could escape into. When things went horribly wrong (and they often did), it was Iggy’s doing not Osterberg’s. It’s almost as if Osterberg had a kind of multiple personality disorder (now called ‘dissociative identity disorder’ [DID]). One definition notes:
“[Dissociative identity disorder] is a mental disorder on the dissociative spectrum characterized by at least two distinct and relatively enduring identities or dissociated personality states that alternately control a person’s behavior, and is accompanied by memory impairment for important information not explained by ordinary forgetfulness…Diagnosis is often difficult as there is considerable comorbidity with other mental disorders”.
I don’t for one minute believe ‘Jim/Iggy’ suffers from DID but a case could possibly made based on the definition above. Some of the things he did on stage in the name of ‘entertainment’ included gross acts of self-mutilation such as stubbing cigarettes out on his naked body, flagellating himself, cutting his chest open with knives and broken glass bottles. He was a sexual exhibitionist and appeared to love showing his penis to the watching audience. On one infamous occasion, he even dry-humped a large teddy bear live on a British children’s television show. (Maybe Iggy is a secret plushophile? Check out the clip on here on YouTube).
In 1975, Iggy was admitted to the Los Angeles Neuropsychiatric Institute (NPI) and underwent treatment (including psychoanalysis) under the care of American psychiatrist Dr. Murray Zucker. After he had completely detoxed all the drugs in his body, Iggy was diagnosed with hypomania (a mental affliction also affecting another of my musical heroes, Adam Ant). This condition was described by Iggy’s biographer Paul Trynka:
“Bipolar disorder [is] characterised by episodes of euphoric or overexcited and irrational behaviour, succeeded by depression. Hypomanics are often described as euphoric, charismatic, energetic, prone to grandiosity, hypersexual, and unrealistic in their ambitions – all of which sounded like a checklist of Iggy’s character traits”.
Dr. Zucker later told Paul Trynka that hypomania tends to get worse with age and it hadn’t with Iggy and therefore the diagnosis of a bipolar disorder may have been wrong. Dr. Zucker now wonders whether “the talent, intensity, perceptiveness, and behavioural extremes” of Iggy were who he truly was “and not a disease…that Jim’s behaviour was simply him enjoying the range of his brain, playing with it, exploring different personae, until it got to the point of not knowing what was up and what was down’. In short, Dr. Zucker (who maintained professional contact with Iggy during the 1980s) claimed Iggy was perhaps “someone who went to the brink of madness just to see what it was like”. Dr. Zucker also claimed that Iggy (like many in the entertainment industry) was a narcissist (“excessive for the average individual” but “unsurprising in a singer…this unending emotional neediness for attention, that’s never enough”). In fact, Iggy went on to write the song ‘I Need More‘ (and was also the title of his autobiography) which pretty much sums him up many of his pychological motivations (at least when he was younger).
It’s clear that Iggy has been drug-free and fit for many years now although many would say that all of his best musical work came about when he was jumping from one addiction to another – particularly during the decade from 1968 to 1978. This raises the question as to whether musicians and songwriters are more creative under the influences of psychoactive substances (but I will leave that for another blog – I’ve just begun some research on creativity and substance abuse with some of my Hungarian research colleagues). I’ll leave the last word with Dr. Zucker (who unlike me) had Iggy as a patient:
“I always got the feeling [Iggy] enjoyed his brain so much he would play with it to the point of himself not knowing what was up and what was down. At times, he seemed to have complete control of turning this on and that on, playing with different personas, out-Bowie-ing David Bowie, as a display of the range of his brain. But then at other times you get the feeling he wasn’t in control – he was just bouncing around with it. It wasn’t just lack of discipline, it wasn’t necessarily bipolar, it was God knows what”.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Ambrose, J. (2008). Gimme Danger: The Story of Iggy Pop. London: Omnibus Press.
Callwood, B. (2008). The Stooges: A Journey Through the Michigan Underworld. London: Independent Music Press.
Pop, I. & Wehrer, A, (1982). I Need More. New York: Karz-Cohl Publishing.
Thompson, D. (2009). Your Pretty Face is Going to Hell: The Dangerous Glitter of David Bowie, Iggy Pop, and Lou Reed. London: Backbeat Books.
Trynka, P. (2007). Open Up and Bleed. London: Sphere.
Wikipedia (2014). Iggy Pop. Located at: http://en.wikipedia.org/wiki/Iggy_Pop
One of the more noticeable ‘extreme’ trends is that of body modification. Arguably the most common (and socially acceptable) forms of body modification are ear piercing and tattoos, followed by various other types of piercings (e.g., nipple piercings) and various types of plastic surgery (e.g., rhinoplasty [nose jobs] and breast augmentation [boob jobs]). More extreme types include foot binding, extreme corseting, branding, amputation, and genital cutting. Such types of actions are known as ‘acquired characteristics’ as they cannot be genetically passed on to the individuals’ children. As the body modification section of the Wikipedia entry on acquired characteristics notes:
“Body modification is the deliberate altering of the human body for any non-medical reason, such as aesthetics, sexual enhancement, a rite of passage, religious reasons, to display group membership or affiliation, to create body art, shock value, or self-expression. The frequency of occurrence depends on the location, extent, and number of modifications, and, perhaps most importantly, on the mind of each individual being asked to accept the modifications on another”.
In a recent issue of the Archives of Sexual Behavior, Dr. David Veale and Dr. Joe Daniels added that:
“Body modification is a term used to describe the deliberate altering of the human body for non-medical reasons (e.g., self-expression). It is invariably done either by the individual concerned or by a lay practitioner, usually because the individual cannot afford the fee or because it would transgress the ethical boundaries of a cosmetic surgeon. It appears to be a lifestyle choice and, in some instances, is part of a subculture of sadomasochism. It has existed in many different forms across different cultures and age”.
These definitions of body modification would also appear to include such practices as circumcision (although this may of course be done for legitimate medical reasons as well as cultural and/or religious rites of passage). Other ‘extreme’ forms of body modification include:
- Earlobe stretching: This refers to the gradual stretching of the earlobe through the gradual increase in size of piercing rings. This is typically carried out for aesthetic reasons, self-expression and/or group membership.
- Branding: This refers to the deliberate burning of the skin to produce an irreversible symbol, sign, ornament and/or pattern on human skin. This is typically carried out for group membership reasons (but can also be carried out for aesthetics and/or self-expression).
- Subdermal Implants (pocketing): This refers to a type of body jewelry placed underneath the skin and often used in conjunction with other forms of body modification. The body then ‘heals’ over the implant leading to a raised (sometimes 3-D) design. This is almost always done for aesthetic reasons and/or shock value.
- Extraocular implants: This refers to the placing of small pieces of jewelry in the eye by cutting the surface layer of the eye following a surgical incision. Again, this is almost always done for aesthetic reasons and/or shock value.
- Corneal tattooing: This is the practice of injecting a colour pigment into the eye. As with the previous two examples, this is almost always done for aesthetic reasons and/or shock value.
- Tongue splitting: This refers to the splitting of the tongue so that the tongue looks like (for instance) a serpent’s tongue.
- Tooth filing: This refers to the practice of filing teeth (often into the shape of sharp pointed fangs). This may be done for a variety of reasons including group membership, aesthetics and/or self-expression.
- Tightlacing (waist training, corset training): This refers to the use of incredibly tight fitting corsets (typically by women) to produce an archetypal ‘hourglass’ figure. This is typically carried out for aesthetic reasons.
- Pearling (genital beading): This refers to the permanent insertion of small beads beneath the skin of the genitals (such as the labia in women or the foreskin in men). Most of those who engage in pearling do it for aesthetic and/or sexual enhancement reasons (e.g., to increase sexual stimulation during vaginal or anal intercourse).
- Anal stretching: This refers to the gradual stretching of the anus with the use of specialized built for purpose ‘butt plugs’ (typically carried out for sexual enhancement and stimulation).
- Penis splitting (penile bisection): This is the cutting and splitting of a person’s penis from the glans towards the penis base (and which I covered at length – no pun intended – in a previous blog). This is typically done for reasons of sexual stimulation and fetishistic enhancement for either the self and/or sexual partner (although it has also been done for both religious and/or aesthetic reasons).
A really great 2007 review paper by Dr. Silke Wohlrab and colleagues in the journal Body Image examined all the known motivations for body modification (including tattoos and piercings) based on scientific studies and concluded almost all motivations fell into one or more of the following ten categories:
- Beauty, art, and fashion (i.e., body modification as a way of embellishing the body, achieving a fashion accessory and/or as a work of art).
- Individuality (i.e., body modification as a way of being special and distinctive, and creating and maintaining self-identity).
- Personal narratives (i.e., body modification as a form of personal catharsis, and/or self-expression. For instance, it was claimed that some abused women “create a new understanding of the injured part of the body and reclaim possession through the deliberate, painful procedure of body modification and the permanent marking”).
- Physical endurance (i.e., body modification as a way of testing a person’s own threshold for pain endurance, overcoming personal limits, etc.).
- Group affiliations and commitment (i.e., body modification as part of sub-cultural membership or the belonging to a certain social circle).
- Resistance (body modification as a protest against parents or society).
- Spirituality and cultural tradition (i.e., body modification as part of a spiritual or cultural movement).
- Addiction (i.e., body modification as a physical and/or psychological addiction due to (i) the release of endorphins associated with the pain of undergoing the practice, and/or (ii) the association with memories, experiences, values or spirituality).
- Sexual motivations (i.e., body modification as a way of enhancing sexual stimulation).
- No specific reason (i.e., body modification as an impulsive act without forethought or planning).
The review paper was incredibly thorough and these ten motivations cover everything they came across in the academic study of body modification. Unsurprisingly, the most frequently mentioned motivation was the expression of individuality and the embellishment of the own body. Hopefully I’ll cover some of the more specific body modifications in future blogs.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.
Lemma, A. (2010). Under the skin: A psychoanalytic study of body modification. London: Routledge.
Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.
Rowanchilde, R. (1996). Male genital modification. Human Nature, 7, 189-215.
Veale, D. & Daniels, J. (2012). Cosmetic clitoridectomy in a 33-year-old woman. Archives of Sex Behavior, 41, 725-730.
Wikipedia (2012). Acquired characteristic. Located at: http://en.wikipedia.org/wiki/Acquired_characteristic
Wikipedia (2012). Body modification. Located at: http://en.wikipedia.org/wiki/Body_modification
Wikipedia (2012). Penile subincision. Located at: http://en.wikipedia.org/wiki/Penile_subincision
Wohlrab, S., Stahl, J., & Kappeler, P. M. (2007). Modifying the body: Motivations for getting tattooed and pierced. Body image, 4, 87-95.
Arguably one of the most extreme of human conditions is having congenital insensitivity to pain (CIP). One of the most high profile portrayals of CIP (which is where I first became aware of the condition) was in The Girl Who Played With Fire (the sequel of The Girl With The Dragon Tattoo), where one of the peripheral characters (Ronald Niedermann – ‘The Giant’) had CIP and was seen as physically invulnerable by those around him.
CIP was first reported by Dr. G. Dearborn in 1932 (in the Journal of Nervous and Mental Diseases) and is also known as congenital analgesia. Those with CIP have no capacity to feel physical pain, usually because of a hereditary genetic mutation associated with the body’s pain receptors. However, there are also cases where the causes are non-genetic. For instance, there are a few cases of CIP that appear to be due to an increase in endorphins (the body’s own morphine-like chemicals) in the brain.
Although CIP might sound like a great (almost superhuman) condition to have, individuals with CIP are much more susceptible to death via trauma as they are completely unaware of what damage has been done to their body following accidents (so they can’t feel cuts, know if they have bitten their tongue, or know if they have broken bones). Furthermore, one of the behaviours associated with CIP is self-mutilation (as highlighted in a 2010 case study of a young boy in the Online Journal of Health and Allied Sciences by Dr. Praveen Kumar and his colleagues). Evolutionary psychologists would therefore argue that pain perception is an evolutionary necessity to avoid injury and/or death.
The condition is very rare (for instance, in the US, it is estimated that only around 100 people have the condition). However, there is a higher incidence of the disorder in societies where there is less biodiversity (so-called ‘homogenous societies’). For instance, an interesting 2006 paper by Dr. Jan Minde in the journal Acta Orthopaedica Supplementum reported that in the village of Vittangi (in the north Swedish Municipality of Kiruna) had documented 43 cases. Given the hereditary nature of CIP, many papers tend to report case studies within families. For instance, Dr. D.C. Thrush reported across two papers in a 1973 issue of the journal Brain, the case of four siblings with CIP that all reported numerous painless injuries, bone fractures, and autonomic dysfunction. Similarly, Dr. Karmani and colleagues reported on a family where three out of four children all had CIP in the Journal of the Royal Society for Medicine in 2001. They reported that in relation to the condition:
“Presentation in childhood is commonly at the time of tooth eruption, with biting and self-mutilation of lips, tongue and digits. Pyrexia of unknown origin is another way the condition can show itself in early infancy. Cuts, abrasions and burns of the limbs are common”.
CIP is different from the group hereditary sensory and autonomic neuropathy (HSAN) disorders that inhibit specific sensations (which I’ll hopefully cover in a future blog). A 2002 paper in the Journal of Bone and Joint Surgery by Dr. E. Bar-On and colleagues reported that among those with CIP “musculoskeletal manifestations are very common although the pathology, inheritance, and pathophysiology of these, as well as their relationship to the different subtypes, have only been partially clarified, mainly in case reports”. Other than the incapacity to feel pain, those with CIP are physically normal (although some individuals have difficulty in experiencing different temperatures). The Wikipedia entry on CIP also notes that:
“Children with this condition often suffer oral cavity damage both in and around the oral cavity (such as having bitten off the tip of their tongue) or fractures to bones. Unnoticed infections and corneal damage due to foreign objects in the eye are also seen. Because the child cannot feel pain they may not respond to problems, thus being at a higher risk of more severe diseases or otherwise. In some people with this disorder, there may be a mild intellectual disability”.
Another minority may have CIP in the ‘voltage-gates sodium channel SCN9A’ (and in the words of Vienna by Ultravox, “this means nothing to me”). There is a series of papers published by Dr. James Cox and his colleagues in journals like Nature and Human Mutation examining the hard-core genetics of CIP. I had hoped that the Wikipedia entry on the genetics of CIP might dumb things down a little but after reading the following, I am still generally none-the-wiser:
“Patients with such mutations are congenitally insensitive to pain and lack other neuropathies. There are three mutations in SCN9A: W897X, located in the P-loop of domain 2; I767X, located in the S2 segment of domain 2; and S459X, located in the linker region between domains 1 and 2. This results in a truncated non-functional protein…it is expected that a loss of function mutation in SCN9A will lead to abolished nociceptive pain propagation”.
Some people working in the field distinguish between pain insensitivity and pain indifference. Pain insensitivity refers to individuals who have absolutely no perception of the stimulus to pain (i.e., they are unable to describe the type or intensity of pain). Pain indifference refers to individuals that have perception of the stimulus to pain have inappropriate responses to the pain stimulus (e.g., they wouldn’t flinch if something very hot or on fire touched their flesh).
Finally, Dr. Praveen Kumar and colleagues report in the Online Journal of Health and Allied Sciences that there is “no single gold standard treatment available” for CIP and that there are some studies suggesting (the opioid antagonists) naloxone and naltrexone (most often used in the treatment of drug addictions) can be used to reverse the analgesic effects of CIP. However, they also note that treatment with opioid antagonists “lacks evidence and further support” and that most treatments are concerned with other associated conditions.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Bar-On, E., Weigl, D., Parvari, R., Katz, K., Weitz, R. & Steinberg, T. (2002). Congenital insensitivity to pain. Journal of Bone and Joint Surgery, 84, 252-257.
Cox, J.J., Reimann, F. & Nicholas, A.K. (2006). An SCN9A channelopathy causes congenital inability to experience pain. Nature, 444, 894–8.
Cox, J.J., Sheynin, J., Shorer, Z., et al (2010). Congenital insensitivity to pain: Novel SCN9A missense and in-frame deletion mutations. Human Mutation, 31, E1670-E1686.
Dearborn, G. (1932). A case of congenital general pure analgesia. Journal of Nervous and Mental Diseases, 75, 612–615.
Karmani, S., Shedden, R. & De Sousa, C. Orthopaedic manifestations of congenital insensitivity to pain. Journal of the Royal Society of Medicine, 94, 139-140
Kumar, P.B, Sudhakar S. & Prabhat, M.P.V. (2010). Case report: Congenital insensitivity to pain. Online Journal of Health and Allied Sciences, 9(4).
Manfredi, M., Bini, G., Cruccu, G., Accornero, N., Berardelli, A. & Medolago, L. (1981). Congenital absence of pain”. Archives of Neurology, 38, 507-511.
Minde J (2006). Norrbottnian congenital insensitivity to pain. Supplementum 77, 2-32.
Nagasakoa, E.M., Oaklanderb, A.L., Dworkin, R.H. (2003). Congenital insensitivity to pain: an update. Pain, 101, 213–219.
Thrush, D.C. (1973). Congenital insensitivity to pain: A clinical, genetic and neurophysiological study of four children from the same family. Brain, 96, 369-86.
Thrush, D.C. (1973). Autonomic dysfunction in four patients with congenital insensitivity to pain. Brain, 96, 591-600.
Wikipedia (2012). Congenital insensitivity to pain. Located at: http://en.wikipedia.org/wiki/Congenital_insensitivity_to_pain
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.
In a previous blog I examined the rare act of genital self-mutilation (GSM) in males. More rare are cases of female genital self-mutilation. Back in 1970, Goldfield and Glick first described a syndrome of dysorexia (i.e.. disordered and/or unnatural appetite) and GSM in the Journal of Nervous Diseases. Of the cases reported since 1970, the majority of cases reported have had personality disorders (typically borderline personality disorder) and a history of childhood sexual abuse. In the Journal of Sex and Marital Therapy, Wise and colleagues categorized female GSM into three groups: (i) patients with personality disorders, (ii) self-induced aborters and (iii) psychotic patients. This slightly differs from male GSM where the cases have been categorized into: schizophrenics, transsexuals (i.e., those with a gender identity crisis), those with complex cultural and religious beliefs, and a small number of severely depressed people who engage in GSM as part of a suicide attempt.
Excluding injuries secondary to self-induced abortion or the insertions of foreign bodies in children, to date, only a handful of female genital self-mutilation have been reported in the literature. Some papers have discussed the differences between self-induced abortion and GSM. However, the differential diagnosis has become increasingly rare because abortion laws have become liberal in many countries.
An early 1957 case in the Journal of Mount Sinai Hospital described a patient who mutilated her vagina on four occasions with a hatpin and knitting needle in late pregnancy that eventually led to a Caesarean section. The 1970 case in the Journal of Nervous Diseases (above) involved a 19-year old female who scratched and gorged her internal genitalia with her fingernails and led to a lot of vaginal bleeding that needed medical attention. A 1972 case in the Archives of General Psychiatry reported the case of a woman who lacerated her vulva with a razor blade.
Following one instance of sexual intercourse with her boyfriend, she feared pregnancy and subsequently penetrated her vagina with a knitting needle. This particular act was not her first episode of self-mutilation. For instance, she had previously swallowed dangerous metal objects, cut her wrists, and had inflicted a deep laceration on her left breast. She also began inserting objects into her vagina including (on one occasion) a twig that had to be medically removed. She later lacerated her vulva and vagina with a knitting needle and a kitchen knife. While in hospital she smashed a window on the gynaecology ward and slashed her arm. Several months later, she again ended up in casualty having cut her vagina with scissors on the previous day, sustaining multiple superficial lacerations of the vagina and cervix.
A detailed case study was reported in 1974 by Simpson and Anstee in the Postgraduate Medical Journal. The authors reported that her self-mutilating behaviour shared several features with the typical wrist cutters (e.g., planning the incident carefully, enjoying the anticipation of the event). She felt no pain when cutting and felt relief and fascination when watching blood flow from her vagina.
There have been a few reports of female GSM associated with psychosis and one 1989 report in the Journal of Sex and Marital Therapy reported an association between, an isolated delusional system, and body dysmorphic disorder. In fact, the feelings of a distorted body image have been noted in a couple of cases where the women view their genitals as abnormal, and as a consequence tried to remove them.
In a 2005 issue of the German Journal of Psychiatry, Dr. Silke Marckmann and colleagues reported the case of a female with paranoid psychosis who had injured her external genitals in an attempt to stop coenaesthetic dysaesthesias (i.e., feelings of abnormal sensations which in this case was described as “feeling like an electric current” running through her genitals). They also noted that in this particular case, secondary erotomania was a feature associated with female GSM. (Erotomania is a type of delusion where the affected person believes that another person is in love with them). The authors also reported that:
“In the last months before hospital admission she felt that the dysaesthesias did not allow her to concentrate on anything else which included eating. She lost 10 kg weight in the 2 months before she agreed to hospital admission. She then reported, that she had been hitting herself repeatedly in the genital area in the attempt to stop the dysaesthesias”
However, the condition is complex and as Dr Nagaraja Rao and colleagues highlighted in the Indian Journal of Psychiatry, that “genital self mutilation like any other serious self injury is not a single clinical entity and it occurs in any psychiatric condition with corresponding psychopathology”.
Marckmann and colleagues believe that compared to male GSM, female GSM might be underreported. This is because they speculate there may be a bias towards those individuals with GSM needing acute medical attention (e.g., men cutting of their penis and/or testicles). Female self-mutilators may find it easier to hide their chronic self-inflicted genital injuries and not seek immediate medical help. Such GSM injuries may be more likely to be spotted by gynaecologists (and as Marckmann and colleagues note, there have been increased reporting of female GSM case studies in gynaecological journals such as the Journal of Obstetrics and Gynaecology and European Journal of Obstetric, Gynecological and Reproductive Biology).
Ajibona, O.O. & Hartwell, R. (2002). Feigned miscarriage by genital self-mutilation in a hysterectomised patient. Journal of Obstetrics and Gynaecology, 22, 451.
Alao, A.O., Yolles, J.C & Huslander, W. (1999). Female genital self- mutilation. Psychiatric Services, 50, 971.
French, A.P.& Nelson, H.L. (1972). Genital self-mutilation in women. Archives of General Psychiatry, 27, 618.
Gersble, M.L., Guttmacher, A.F. & Brown, F. (1957). A case of recurrent malingered placenta praevia. Journal of Mount Sinai Hospital, 24, 641.
Goldfield, M.D. & Glick, I.R. (1970). Self-mutilation of the female genitalia: a case report. Diseases of the Nervous System, 31, 843.
Habek, D., Barbir, A., Galovic, J., Habek, J.C. et al. (2002). Autosection of the prolapsed uterus and vagina. European Journal of Obstetric, Gynecological and Reproductive Biology, 103, 99-100.
Krasucki, C, Kemp, R., & David A. (1995). A case study of female genital self-mutilation in schizophrenia. British Journal of Medical Psychology, 68, 179-186
Marckmann, S., Garlipp, P., Krampfl, K., & Haltenhof. H. (2005). Genital self-mutilation and erotomania. German Journal of Psychiatry. Located at: http://www.gjpsy.uni-goettingen.de
Simpson, M.A. & Anstee, B.H. (1974). Female genital self-mutilation as a cause of vaginal bleeding. Postgraduate Medical Journal, 50, 308-309.
Standage, K.F., Moore, J.A,. & Cole, M.G. (1974). Self-mutilation of the genitalia by a female schizophrenic. Canadian Psychiatric Association Journal, 19, 17-20.
Wise, T.N., Dietrich, A.M. & Segall, E. (1989). Female genital self- mutilation: Case reports and literature review. Journal of Sex and Marital Therapy, 15, 269-274
If I was playing a word association game and said the words ‘self-inflicted ear mutilation’, I would hazard an educated guess that the first thing that popped into most people’s minds would be the Dutch artist Vincent Van Gogh. On the evening of December 23, 1888, in Aries (France) Van Gogh (in a state of deep depression) cut off the lower part his own right ear with a razor (and later immortalized in his famous painting Self Portrait With Bandaged Ear). Earlier in the day he had threatened his long-time friend and artist Paul Gaugin with a razor and was not in a good state of mind (both that day and in life more generally). Van Gogh had become a heavy smoker and heavy drinker and had taken a liking to the alcoholic drink absinthe. After cutting off his ear, he took it over to a local brothel and gave it to a prostitute called Rachel (telling her to take good care of it). He would have died of blood loss but the local police took him to the hospital.
This incident has given rise to what has been called the Van Gogh Syndrome which has now become a catch-all term for self-mutilation, particularly in relation to amputation of a bodily extremity (such as the cutting off of one’s own penis, or the removal of one’s own eye). Such actions may be due to a wide range of conditions including psychoses, mood disorders (e.g., clinical depression), body dysmorphic disorder, or as a component of Lesch-Nyhan syndrome (a genetic disorder that affects how the human body builds and breaks down purines).
Van Gogh would have been classed as a ‘psychotic self-mutilator’ in psychiatrist Karl Menninger’s self-mutilation typology developed in the 1930s. He proposed that self-mutilators fall into one of six categories:
- Neurotic self-mutilators: These individuals comprise nail biters and pickers, extreme hair removal and those seeking unnecessary cosmetic surgery.
- Religious self-mutilators: These individuals comprise self-flagellators and/or genital self-mutilators.
- Puberty rite self-mutilators: These individuals comprise those who engage in hymen removal, circumcision or clitoral alteration.
- Psychotic self-mutilators: These individuals engage in eye or ear removal, genital self-mutilation and extreme amputation.
- Organic disease self-mutilators: These individuals comprise those who engage in repetitive head banging or hand biting, intentionally fracturing fingers and eye removal, due to diseases such as encephalitis or disorders such as severe mental retardation.
- Conventional self-mutilators: These individuals comprise normal people that engage in customary or conventional forms of self-mutilation (that most would argue is not self-mutilation at all, e.g., nail clipping, hair trimming, and beard shaving).
More recent typologies tend to talk about self-harm rather than self-mutilation and class such behaviour into one of three types (i.e., psychotic, organic or typical). Again, Van Gogh would be classed as a psychotic self-harmer:
- Psychotic self-harmers: These individuals comprise those who remove or amputate body parts (e.g., eyes, limbs, ears, genitals, digits). In these cases, body part removal is carried out in response to hallucinations bought on by psychosis. Unsurprisingly, this is the most severe type of self-harming.
- Organic self-harmers: These individuals comprise those who self-harm in the form of behaviours such as head-banging and lip-biting because of conditions such as Autistic Spectrum Disorders, developmental disabilities, and other similar disorders. Here the self-harm is a consequence of physical or chemical issues in the body.
- Typical self-harmers: These individuals comprise those who self-harm in the form of self-cutting, burning, hair-pulling (trichotillomania), skin-picking (dermotillomania), biting, hitting, interference with wound healing, scratching or bone-breaking. Here, the self-harm is initiated by emotional or psychological trauma that is unrelated to psychotic or organic conditions. This is the most common type of self-harming.
In a 2006 issue of the Journal of Deaf Studies and Deaf Education, Dr. David Veale reported that major self-injurious behaviours tend to “be very isolated events and consists of severe or life-threatening tissue damage, such as self-castration, eye nucleation, or less commonly self-amputation of a limb or ear. They mainly occur in young psychotic men or older males with psychotic depression usually in the context of command auditory hallucinations or delusions of guilt”.
Despite the fact that self-inflicted ear mutilation is well documented, there are surprisingly few published case studies. In 1989, Dr. J. Silver and colleagues published a case study of self-inflicted ear mutilation (as part of wider self-mutilation) in the journal Psychosomatics. Their case was a 35-year old male paranoid schizophrenic who presented for treatment following dermatological self-mutilation following severe lacerations (including the ear, arms, and face). They concluded that the self-mutilation behaviour appeared to be associated with his psychotic symptoms, and that the self-mutilation was exacerbated by failure to take his neuroleptic medication.
Dr. Christopher Alroe and Dr. Venkat Gunda reported some cases of self-inflicted ear mutilations in a 1995 issue of the Australian and New Zealand Journal of Psychiatry. They presented three cases of self-amputation of the ear by three white right-handed men. All three men had psychiatric problems (one having schizophrenia and two having personality disorders. They compared their cases with that of van Gogh. The authors also surveyed all Australian and New Zealand prisons to determine the frequency of self-mutilation of the ears within the last five years. They found only one other case. Based on the cases, they argued that connections exist between the self-amputees and supports the notion that self-mutilation is “contagious”.
It is also worth noting that there are cases of people who have cut off their ears but would not be classed as psychotic because they have done it for a very specific reason. The most recent case was that of British prisoner Michael O’Donnell who (on May 2, 2010) cut off his ear so that he could escape from an ambulance while he was being transported to hospital for treatment. In the end, it was all in vain as he was caught and re-arrested three weeks later.
Alroe, C.J., & Gunda, V. (1995). Self-Amputation of the Ear: Three Men Amputate Four Ears within Five Months. Australian and New Zealand Journal of Psychiatry, 29, 508-512.
Edwards, G. (1998). A brief history of ear mutilation. Deluxe. Located at: http://rulefortytwo.com/articles-essays/gallimaufry/ear-mutilation/
Menninger, K. (1935). A psychoanalytic study of the significance of self-mutilation. Psychoanalytic Quarterly, 4, 408-466.
Menninger, K. (1938). Man Against Himself. New York: Jovanovich.
Silva, J.A., Leong, G.B. & Weinstock, R. (1989). A case of skin and ear self-mutilation. Psychosomatics, 30, 228-230.
Press Association (2010). Prisoner who cut off ear to escape is recaptured. The Guardian, May 28. Located at: http://www.guardian.co.uk/uk/2010/may/28/prisoner-cut-off-ear-recaptured
Veale, D. (2006). A compelling desire for deafness. Journal of Deaf Studies and Deaf Education, 11, 369-372.
One of the rarest behaviours in the world is the act of genital self-mutilation (GSM) in males. To date, approximately 125 cases have been recorded in the clinical literature dating back to the turn of the twentieth century. The first recorded case is thought to be a letter in the Journal of the American Medical Association by Dr D. Stroch in 1901.
GSM has been recorded in a variety of forms (e.g., simple lacerations, scrotal cutting, testicle removal, penile amputations, self-castration, and a combination of the above, so called ‘lock, stock and barrel mutilation’) across a variety of countries (USA, Middle East, India, Kenya, and Nigeria). There appears to be an increased incidence of GSM over the last decade although this may be due to increased reporting rather than increasing number of cases. GSM usually occurs in Caucasian men in the 20s and 30s (although there is a minority of cases from African and Indian descent and some case reports of individuals over the age of 70 years).
The range of instruments used to enable GSM include kitchen knifes, Stanley knives, scissors, blades, chain saw, and axe. In many cases, the genitals are disposed of immediately such as a recent case reported in the Saudi Medical Journal where a 37-year old male schizophrenic cut off both his penis and testicles and flushed them down the toilet.
A 1988 study by Tobias and colleagues 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 (particularly command hallucinations), religious preoccupation, substance abuse, and/or social isolation. Genital self-mutilators are similar, and tend to fall into one of four types – schizophrenics, transsexuals (i.e., those with a gender identity crisis), those with complex cultural and religious beliefs, and a small number of severely depressed people who engage in GSM as part of a suicide attempt (around one-tenth of cases). A 1991 study in the journal Psychopathology also reported that GSM may also be triggered by a feeling of guilt for sexual offences. Similarly, Dr A.C. Waugh writing in the British Journal of Psychiatry concluded that GSM most commonly occurred in men with chronic paranoid schizophrenia and a history of delusions where only castration absolves them of guilt for sexual wrongdoing
A 2003 case report in the journal Urology, reported an attempt by an Indian man to become a ‘hijra’ (i.e., eunuch of the Indian subcontinent) due to his dissatisfaction with the wait for gender reassignment surgery. Reports indicate that transsexuals often resort to genital self-mutilation especially if they are unaware of the availability of professional (medical) help. Dr. D.B. Russell and colleagues in a 2005 issue of Sexual Health reported that genital mutilation that has a more ‘rational’ basis usually involves removal of the testicles (i.e., auto-castration) whereas those in a psychotic state are more likely to engage in penile amputation. An early study in 1993 by Aboseif and colleagues in the Journal of Urology reported that among a group of 14 genital self-mutilators, 61% of episodes involved the mutilation of one or both testicles. They also reported that among repeat mutilators, around one-third (31%) had a history of alcohol abuse and over a half (55%) had a history of drug abuse. The degree of injury didn’t differ between the psychotic and non-psychotic self-mutilators. Reporting on 52 cases in the Archives of General Psychiatry, Greilsheimer and Groves found 87% of genital self-mutilators to be psychotic and 13% to be non-psychotic. The psychotic individuals ranged from those with functional psychosis through to those with brain damage.
Those who engage in GSM as part of a religious belief are typically diagnosed as having Klingsor Syndrome. This 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. According to Samir Shirodkar and colleagues in the Saudi Medical Journal, group genital mutilation is a custom of a sect of Australian Aborigines where the blood is drunk by the infirm (who believe it restores their health).
In a fairly recent issue of the journal Mental Health and Substance Use, Dr Thomas Dunn and colleagues reported an unusual case of GSM. A 55-year-old non-psychotic homeless male turned up at hospital with penis and scrotal maggot infestation that was secondary to GSM. The man had gender identity issues and had performed GSM while he was drunk. However, he only sought medical help when he was barred from travelling on public transport because of the smell emanating from his maggot infection.
In a 2007 issue of the Jefferson Journal of Psychiatry, Dr. Craig Franke and Dr James Rush provided some risk factors that help in the identification of people at risk for GSM. These included: (i) psychotic patients with delusions of sexual guilt, (ii) psychotic patients with sexual conflict issues, (iii) prior self-destructive behaviour, (iv) depression, (v) severe childhood deprivation, and (vi) pre-morbid personality disorders. However, the condition is complex and as Dr Nagaraja Rao and colleagues highlighted in the Indian Journal of Psychiatry, “genital self mutilation like any other serious self injury is not a single clinical entity and it occurs in any psychiatric condition with corresponding psychopathology”.
Aboseif, S., Gomez, R. & McAninch, J.W. (1993). Genital self-mutilation. Journal of Urology, 150, 1143-1146.
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.
Dunn, T.M., Collins, V., House, R.M. & Dunn, P.W. (2009). Male genital self-mutilation with maggot infestation in an intoxicated individual. Mental Health and Substance Use, 2, 235-238.
Eke N. (2000). Genital self-mutilation: there is no method in this madness. BJU International, 85, 295-298.
Franke, C.B. & Rush, J.A. (2007). Autocastration and autoamputation of the penis in a patient with delusions of sexual guilt. Jefferson Journal of Psychiatry, 21, Located at: jdc.jefferson.edu/jeffjpsychiatry
Greilsheimer, H. & Groves, J.E. (1979). Male genital self-mutilation. Archives of General Psychiatry, 36, 441.
Martin, T. & Gattaz, W.F. (1991). Psychiatric aspects of male genital mutilations. Psychopathology, 24, 170.
Master, V. & Santucci, R. (2003). An American hijra: A report of a case of genital self-mutilation to become India’s ‘‘third sex’’. Urology, 62, 1121.
Murota-Kawano, A, Tosaka, A. & Ando, M. (2001). Autohemicastration in a man without schizophrenia. International Journal of Urology, 8, 257-259.
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.
Shirodkar, S.S., Hammad, F.T. & Qureshi, N.A. (2007). Male genital self-amputation in the Middle East: A simple repair by anterior urethrostomy. Saudi Medical Journal, 28, 791-793.
Stroch, D. (1901). Self castration (Letter to the Editor). Journal of the American Medical Association, 36, 270.
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.
Waugh, A.C. (1986). Autocastration and biblical delusions in schizophrenia. British Journal of Psychiatry, 149, 656-658.