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Möllmann A, Heinrichs N, Herwig A. A conceptual framework on body representations and their relevance for mental disorders. Front Psychol 2024; 14:1231640. [PMID: 38250111 PMCID: PMC10796836 DOI: 10.3389/fpsyg.2023.1231640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Many mental disorders are accompanied by distortions in the way the own body is perceived and represented (e.g., eating disorders, body dysmorphic disorder including muscle dysmorphia, or body integrity dysphoria). We are interested in the way these distortions develop and aim at better understanding their role in mental health across the lifespan. For this purpose, we first propose a conceptual framework of body representation that defines this construct and integrates different perspectives (e.g., cognitive neuroscience, clinical psychology) on body representations. The framework consists of a structural and a process model of body representation emphasizing different goals: the structural model aims to support researchers from different disciplines to structure results from studies and help collectively accumulate knowledge about body representations and their role in mental disorders. The process model is reflecting the dynamics during the information processing of body-related stimuli. It aims to serve as a motor for (experimental) study development on how distorted body representations emerge and might be changed. Second, we use this framework to review the normative development of body representations as well as the development of mental disorders that relate to body representations with the aim to further clarify the potential transdiagnostic role of body representations.
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Affiliation(s)
- Anne Möllmann
- Department of Psychology, Faculty of Psychology and Sports Science, Bielefeld University, Bielefeld, Germany
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Capodici A, Pennisi A, Rizzo G, Falzone A, Vicario CM. Interoceptive and Affective Alterations in Body Integrity Dysphoria: An Online Self-Reporting Study. Psychopathology 2023; 57:102-110. [PMID: 37820588 DOI: 10.1159/000532076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/14/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Body integrity dysphoria (BID) is a rare condition in which individuals experience a long-lasting desire to achieve a specific physical disability. In this study, we tested the hypothesis of interoceptive and affective abnormalities in BID, in line with the evidence of structural and functional alteration of the interoceptive-affective neural system in these individuals. METHOD Our study involved 68 participants with BID (mean age: 35.6, SD: 16.4). Among these participants, 47 expressed a desire for amputation, 14 desired paralysis, 3 sought sensory deprivation, and 3 desired a combination of these forms. For comparisons, we recruited a control group of 79 participants (mean age: 35.2, SD: 15.8). We administered assessment measures to investigate alexithymia level (TAS-20), disgust sensitivity (DS-R), interoceptive awareness (MAIA-2), and (affective and cognitive) empathy (QCAE). We also administered the Short Oxford-Liverpool Inventory of Feelings and Experiences (O-LIFE) to identify psychiatric comorbidities. Subgroups with low O-LIFE scores (BID = 31; controls = 43) and subgroups with high O-LIFE scores (BID = 37; controls = 36) were derived through a median-split procedure. RESULTS Within the BID low O-LIFE group, we found reduced interoceptive sensibility, reduced disgust sensitivity, and increased difficulty in identifying feelings, which refers to a dimension of the alexithymia trait. Within the BID high O-LIFE group, we observed a reduced disgust sensitivity and interoceptive sensibility, accompanied by a diminished score in cognitive empathy. CONCLUSION Our study suggests that BID can be associated with altered interoceptive and affective processing.
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Affiliation(s)
- Alessandro Capodici
- Department of Cognitive Science, Psychological, Pedagogical and Cultural Studies, University of Messina, Messina, Italy
| | - Antonio Pennisi
- Department of Cognitive Science, Psychological, Pedagogical and Cultural Studies, University of Messina, Messina, Italy
| | - Gaetano Rizzo
- Department of Cognitive Science, Psychological, Pedagogical and Cultural Studies, University of Messina, Messina, Italy
| | - Alessandra Falzone
- Department of Cognitive Science, Psychological, Pedagogical and Cultural Studies, University of Messina, Messina, Italy
| | - Carmelo Mario Vicario
- Department of Cognitive Science, Psychological, Pedagogical and Cultural Studies, University of Messina, Messina, Italy
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Retrouvey H, Franks A, Dunn T, Novoa K, Ipaktchi K, Lauder A. Management of Self-Inflicted Nonaccidental Amputations of the Upper Extremity: Systematic Review. J Hand Surg Am 2023; 48:993-1002. [PMID: 37589622 DOI: 10.1016/j.jhsa.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 05/17/2023] [Accepted: 06/14/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE Clinicians assessing patients with deliberate self-inflicted amputations face a problem of whether or not to replant. The objective of this study was to summarize the literature on this topic and provide recommendations regarding the acute management of patients following self-inflicted amputations in the upper extremity. METHODS Two reviewers searched four databases using the keywords "Upper extremity," "Amputation," and "Self-Inflicted." The reviewers systematically screened and collected data on publications reporting cases of self-inflicted upper-extremity amputations. The findings then were summarized in a narrative fashion. RESULTS Twenty-four studies were included. Twenty-nine cases of self-inflicted upper-extremity amputations were reported. There were 25 unilateral and four bilateral extremity amputations. Amputations were most commonly at the hand/wrist (18 patients) and forearm level (6 patients). The amputations were most commonly performed with a saw (9 patients) or a knife (8 patients). Reasons for amputation included psychosis (10 cases), suicide attempt (7 cases), depression (5 cases), and body integrity identity disorder (four cases). Fifteen replantations were performed; all were successful. Reasons for not pursuing replantation were related to injury factors (ie, multilevel injury, prolonged ischemia, damaged part) rather than patient-level factors. Two patients with replantable extremities declined replantation, both of whom had body integrity identity disorder. Of the patients who underwent replantation, none expressed regret. CONCLUSIONS The literature shows that patients experiencing psychosis or depression committed self-harm during an acute psychiatric decompensation, and once medically and psychiatrically stabilized, expressed satisfaction with their replanted limb. Surgeons should not consider psychiatric decompensation a contraindication to replantation and should be aware of patients with body integrity identity disorder who consciously may elect to undergo revision amputation. When presented with patients experiencing psychiatric decompensation who refuse replantation/are not competent, surgeons should seek emergency assistance from the psychiatry team to determine the best management of a self-inflicted amputation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapy/Prevention/Etiology/Harm V.
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Affiliation(s)
- Helene Retrouvey
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO.
| | - Amy Franks
- Division of Psychiatry, Denver Health Medical Center, Denver, CO
| | - Thom Dunn
- Division of Psychiatry, Denver Health Medical Center, Denver, CO
| | - Kenneth Novoa
- Division of Psychiatry, Denver Health Medical Center, Denver, CO
| | - Kyros Ipaktchi
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO
| | - Alexander Lauder
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO
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Scattolin M, Panasiti MS, Ho JT, Lenggenhager B, Aglioti SM. Ownership of the affected leg is further reduced following deceptive behaviors in body integrity dysphoria. iScience 2023; 26:107551. [PMID: 37664627 PMCID: PMC10469995 DOI: 10.1016/j.isci.2023.107551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/06/2023] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Although predicted by the notion of embodied morality, it remains unknown whether a reduced sense of body ownership (SoO) is associated with increased or decreased dishonesty. To clarify this issue, we tested patients with body integrity dysphoria (BID), a clinical condition characterized by chronic reductions of SoO toward one leg that patients persistently desire to have amputated. Participants with BID played a card game in which they could voluntarily tell the truth or cheat an opponent, and thus either steal or give them money. To assess whether SoO toward the effector limb influences (im)moral decisions, responses were communicated with the affected or the unaffected leg. We found that a higher number of self-gain lies was followed by further reductions of SoO toward the affected leg. Our result supports the idea that reductions of SoO may follow immoral behaviors to distance from unwanted characteristics of the self, like one's own dishonesty.
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Affiliation(s)
- Marina Scattolin
- Sapienza University of Rome and CLNS@Sapienza, Italian Institute of Technology, Rome (RM) 00161, Italy
| | - Maria Serena Panasiti
- Santa Lucia Foundation, IRCCS, Rome (RM) 00179, Italy
- Department of Psychology, Sapienza University of Rome, Rome (RM) 00185, Italy
| | - Jasmine T. Ho
- Department of Psychology, University of Zurich, 8050 Zurich, Switzerland
- Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, 8032 Zurich, Switzerland
| | - Bigna Lenggenhager
- Department of Psychology, University of Zurich, 8050 Zurich, Switzerland
- Department of Psychology, University of Konstanz, 78457 Konstanz, Germany
| | - Salvatore Maria Aglioti
- Sapienza University of Rome and CLNS@Sapienza, Italian Institute of Technology, Rome (RM) 00161, Italy
- Santa Lucia Foundation, IRCCS, Rome (RM) 00179, Italy
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Retrouvey H, Lauder A, Ipaktchi K. Is self-inflicted amputation to the upper extremity a contraindication to replantation? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03669-w. [PMID: 37581643 DOI: 10.1007/s00590-023-03669-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
PURPOSE Contraindications to replantation include severe medical or psychiatric comorbidities. Recently, authors have suggested that due to the improving therapeutic options for patients with psychiatric decompensation, this should no longer be listed as a contraindication to replantation. Despite this, authors continue to list severe psychiatric comorbidities as a contraindication to replantation. This case series and review of the literature discusses this complex topic and provides recommendations regarding the management of patients following upper extremity self-inflicted amputations. METHODS The authors present two cases of self-inflicted upper extremity amputations. The cases depict the acute management and the outcomes of these patients. The authors also reviewed the literature to present the available literature on this topic. RESULTS The first case is a 64-year-old male who deliberately amputated his left hand with a table saw while suffering postictal psychosis. He underwent replantation. The patient was co-managed by the surgical and psychiatric team postoperatively. The patient expressed gratitude for his replantation after being treated for his psychoneurological condition. The second case is that of a 25-year-old male who deliberately amputated his left forearm using a Samurai sword. The patient's limb was successfully replanted. In the post-anesthesia care unit, the patient experienced extreme agitation, and during this event, he reinjured the left forearm. He was again taken urgently to the operating room to revise the replantation. Once psychiatrically stabilized, the patient was thankful for the care he received. CONCLUSION The management of upper extremity self-inflicted amputations is controversial and difficult to establish as this presentation is rare. We present two cases which illustrate some of the nuances in the care of these patients. Our review suggests that psychiatric diagnosis be viewed as a comorbidity and not a contraindication to replantation. Thus, an informed consent discussion should be performed with the patients and, as needed, a member of the psychiatric team in order to decide whether to replant or not.
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Affiliation(s)
- Helene Retrouvey
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, CO, 80045, Aurora, USA.
| | - Alexander Lauder
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, CO, 80045, Aurora, USA
| | - Kyros Ipaktchi
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, CO, 80045, Aurora, USA
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Weijs ML, Ho JT, Roel Lesur M, Lenggenhager B. Is this my foot? Experimentally induced disownership in individuals with body integrity dysphoria. Conscious Cogn 2022; 106:103432. [PMID: 36372053 DOI: 10.1016/j.concog.2022.103432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/07/2022] [Accepted: 10/14/2022] [Indexed: 11/12/2022]
Abstract
In body integrity dysphoria (BID), otherwise healthy individuals feel like a part of their physical body does not belong to them despite normal sensorimotor functioning. Theoretical and empirical evidence suggested aweakened integration of the affected body part into higher-order multisensory cortical body networks. Here, we used a multisensory stimulation paradigm in mixed reality to modulate and investigate multisensory processing underlying body (dis)ownership in individuals with BID of the lower limb. In 20 participants with BID, delay perception and body ownership were measured after introducing delays between the visual and tactile information of viewed stroking applied to affected and unaffected body parts. Unlike predicted, delay perception did not differ between the two body parts. However, specifically for the affected limb, ownership was lower and more strongly modulated by delay. These findings might be following the idea of a stronger dependency on online bottom up sensory signals in BID.
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Affiliation(s)
- Marieke L Weijs
- Department of Psychology, University of Zurich, Zurich, Switzerland; Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland.
| | - Jasmine T Ho
- Department of Psychology, University of Zurich, Zurich, Switzerland; Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Zurich, Switzerland
| | - Marte Roel Lesur
- Department of Psychology, University of Zurich, Zurich, Switzerland; Department of Computer Science and Engineering, Universidad Carlos III de Madrid, Madrid, Spain
| | - Bigna Lenggenhager
- Department of Psychology, University of Zurich, Zurich, Switzerland; Department of Psychology, University of Konstanz, Konstanz, Germany
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Ho JT, Krummenacher P, Lenggenhager B. Not my body, not my pain? Pain perception and placebo analgesia in individuals with body integrity dysphoria. Cortex 2022; 153:44-54. [PMID: 35588553 DOI: 10.1016/j.cortex.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/14/2022] [Accepted: 03/04/2022] [Indexed: 11/23/2022]
Abstract
Acute and chronic states of physical pain are inherently linked to our bodily perception. Bodily illusion paradigms have demonstrated that an experimentally induced sense of body disownership can modulate both acute and chronic pain. Insight into the relationship between enduring clinical alterations in body perception and pain is much more limited. The current study examined both pain perception and placebo analgesia in Body Integrity Dysphoria (BID), a clinical model of long-term alterations of bodily disownership: in its most commonly studied variant, people feel like a part of their body does not belong to them, leading to a desire for amputation of a physically healthy limb. Heat stimulations were applied before and after a placebo intervention (sham analgesic cream) to the desired and the undesired leg of 19 patients with BID with a unilateral leg amputation desire. Pain perception was assessed using pain thresholds, and ratings for pain intensity and pain unpleasantness. Results show that pain perception and placebo efficacy were lower for the undesired than for the desired leg, demonstrating a potential link between a clinical disorder of body ownership, pain perception, and placebo analgesia.
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Affiliation(s)
- Jasmine T Ho
- University of Zurich, Department of Psychology, Zurich, Switzerland; Brainability, LLC, Zurich, Switzerland.
| | - Peter Krummenacher
- Brainability, LLC, Zurich, Switzerland; Experimental and Clinical Pharmacopsychology, Department of Psychiatry, Psychotherapy, Psychotherapy and Psychosomatics, Zurich, Switzerland.
| | - Bigna Lenggenhager
- University of Zurich, Department of Psychology, Zurich, Switzerland; Department of Psychology, University of Konstanz, Konstanz, Germany.
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Saetta G, Ruddy K, Zapparoli L, Gandola M, Salvato G, Sberna M, Bottini G, Brugger P, Lenggenhager B. White Matter Abnormalities in the Amputation Variant of Body Integrity Dysphoria. Cortex 2022; 151:272-280. [DOI: 10.1016/j.cortex.2022.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/11/2022] [Accepted: 03/04/2022] [Indexed: 11/28/2022]
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Vašečková B, Patarák M, Petrušová V, Forgáčová Ľ. Self-Amputation in Patient with Body Integrity Dysphoria in Comorbidity with Gender Dysphoria: A Case Report. Psychopathology 2022; 55:310-316. [PMID: 35350028 DOI: 10.1159/000522596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/13/2022] [Indexed: 11/19/2022]
Abstract
We present a rare, atypical case of a 24-year-old transgender male (assigned as a female at birth) admitted to the hospital after the planned self-amputation of his left hand. The patient described his motivation for this self-amputation as coming from deep-rooted and persistent feelings that this hand was not a part of his body. He identified himself as having, according to internet peer group definition, body integrity identity disorder. This condition is now referred to as body integrity dysphoria (BID). This patient was later diagnosed as having gender dysphoria and other conditions, including bipolar disorder and gaming disorder. The follow-up 2 years after self-amputation is presented, during which, despite antipsychotic and antidepressant treatment, the symptoms of BID remained unchanged and the high variability of other psychopathology was observed. This is an unusual case of BID simply because several other comorbidities are presented. Like many other rare clinical situations, this case also presents a particular challenge to our understanding of the dynamics and interrelationships between comorbidities, raising concerns and questions.
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Affiliation(s)
- Barbora Vašečková
- Psychiatric Clinic Slovak Medical University and University Hospital Bratislava, Bratislava, Slovakia.,Psychiatry Outpatient Clinics, University Hospital of The Brothers of Saint John of God in Bratislava, Bratislava, Slovakia
| | - Michal Patarák
- Psychiatric Clinic Slovak Medical University and F.D. Roosevelt University Hospital, Banská Bystrica, Slovakia
| | - Veronika Petrušová
- Psychiatric Clinic Slovak Medical University and University Hospital Bratislava, Bratislava, Slovakia
| | - Ľubica Forgáčová
- Psychiatric Clinic Slovak Medical University and University Hospital Bratislava, Bratislava, Slovakia
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Chakraborty S, Saetta G, Simon C, Lenggenhager B, Ruddy K. Could Brain-Computer Interface Be a New Therapeutic Approach for Body Integrity Dysphoria? Front Hum Neurosci 2021; 15:699830. [PMID: 34456696 PMCID: PMC8385143 DOI: 10.3389/fnhum.2021.699830] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/09/2021] [Indexed: 12/11/2022] Open
Abstract
Patients suffering from body integrity dysphoria (BID) desire to become disabled, arising from a mismatch between the desired body and the physical body. We focus here on the most common variant, characterized by the desire for amputation of a healthy limb. In most reported cases, amputation of the rejected limb entirely alleviates the distress of the condition and engenders substantial improvement in quality of life. Since BID can lead to life-long suffering, it is essential to identify an effective form of treatment that causes the least amount of alteration to the person's anatomical structure and functionality. Treatment methods involving medications, psychotherapy, and vestibular stimulation have proven largely ineffective. In this hypothesis article, we briefly discuss the characteristics, etiology, and current treatment options available for BID before highlighting the need for new, theory driven approaches. Drawing on recent findings relating to functional and structural brain correlates of BID, we introduce the idea of brain-computer interface (BCI)/neurofeedback approaches to target altered patterns of brain activity, promote re-ownership of the limb, and/or attenuate stress and negativity associated with the altered body representation.
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Affiliation(s)
- Stuti Chakraborty
- Occupational Therapy, Department of Physical Medicine and Rehabilitation, Christian Medical College and Hospital, Vellore, India
| | - Gianluca Saetta
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Colin Simon
- Trinity College Institute of Neuroscience and School of Psychology, Trinity College Dublin, Dublin, Ireland
| | | | - Kathy Ruddy
- Trinity College Institute of Neuroscience and School of Psychology, Trinity College Dublin, Dublin, Ireland
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Ramkumar DB, Brown MG, Lewis CY, Warren CE, Fortney TA, Warhold LG. Self-Inflicted Hand Amputation without Replantation in a Patient with Body Integrity Identity Disorder: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00005. [PMID: 34228661 DOI: 10.2106/jbjs.cc.20.00976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We describe a patient who self-amputated his hand using a log splitter, because of a long-standing belief that the limb "did not belong to him." On admission, he refused replantation and was found to be nonpsychotic. He was diagnosed with body integrity identity disorder (BIID) and declared competent to make his own medical decisions. A revision amputation was performed. CONCLUSION BIID is a challenging diagnosis that physicians treating traumatic injuries should be aware of. Many ethicists support elective amputation as a definitive treatment, because of potential harm reduction and because BIID does not respond to conservative modalities such as pharmacotherapy.
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Affiliation(s)
- Dipak B Ramkumar
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Section of Orthopaedic Oncology, Department of Orthopaedic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Marcel G Brown
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Chad Y Lewis
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | | | - Thomas A Fortney
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Lance G Warhold
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Wong STS, Wassersug RJ, Johnson TW, Wibowo E. Differences in the Psychological, Sexual, and Childhood Experiences Among Men with Extreme Interests in Voluntary Castration. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:1167-1182. [PMID: 32935176 DOI: 10.1007/s10508-020-01808-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 05/12/2023]
Abstract
Some genetic males seek voluntary castration. We designed a survey to compare the psychological, sexual, and childhood experiences for subgroups of men with extreme interest in castration. The survey was posted on the Eunuch Archive, an online platform for individuals interested in the topic. Data from 822 individuals were included in the analyses. Respondents were divided into four groups: Interested (claiming only an interest in castration topics), Fantasy (fantasize about castration sexually, but not desiring castration), Wannabe (considering being castrated in the future), and Castrated (already castrated). More individuals desiring castration (Wannabe and Castrated groups) claimed equal attraction to both sexes than individuals in the Interested group. The Interested group was more religious than the other groups, and the Fantasy group had lower sexual guilt than those with castration desire. All groups had similar psychological well-being and body image acceptance, despite the Castrated group having lower sexual functioning than the others. Childhood trauma was more common in those with castration desire than those without. The Interested group had a lower desire for castration, lower erotic attraction to castration, and pretended to be castrated at a younger age than the others. Childhood trauma and sexual guilt are common, but not limited, predictors for castration desire and erotic attraction to castration, respectively. In conclusion, childhood experiences, as well as psychological and sexual parameters, may vary in different subgroups of males with interests in castration.
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Affiliation(s)
- Samantha T S Wong
- Department of Educational and Counselling Psychology, McGill University, Montreal, QC, Canada
| | - Richard J Wassersug
- Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Thomas W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - Erik Wibowo
- Department of Anatomy, University of Otago, 270 Great King Street, Dunedin, 9016, New Zealand.
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Abstract
This paper explores the impact that developments in the field of neuroprosthetics will have on the ethical viability of healthy limb amputation, specifically in cases of Body Integrity Identity Disorder (BIID). Developments in the field have meant that the prospect of such artificial components matching the utility of their biological counterparts is now a possibility. As such, arguments against the provision of therapeutic, healthy limb amputation, which are grounded in the perceived resultant harm of disability, need to be reconsidered. Drawing on philosophical insights, as well as the field of disability studies and BIID research, this paper argues that such neuroprosthetics presents a challenge for the fundamental dichotomy between the disabled and non-disabled, including the latter's perceived superiority. It goes on to suggest that healthy limb amputation, for those with BIID, should not be dismissed simply because of the distastefulness of the procedure, but rather be evaluated based upon its own merits.
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Affiliation(s)
- Richard B Gibson
- The Centre for Social Ethics and Policy, The University of Manchester Law School, Manchester, UK
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14
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Turbyne C, Koning PD, Zantvoord J, Denys D. Body integrity identity disorder using augmented reality: a symptom reduction study. BMJ Case Rep 2021; 14:e238554. [PMID: 33431465 PMCID: PMC7802686 DOI: 10.1136/bcr-2020-238554] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 11/30/2022] Open
Abstract
Body integrity identity disorder (BIID) is a rare condition characterised by a discrepancy between specific areas of an individual's perceived body image and body schema which causes the individual to disassociate those physical areas of their body from their internal representation. There are currently no efficacious, ethically unambiguous means for achieving long-lasting symptom reductions. In the case we present, two patients with BIID underwent an augmented reality (AR)-based simulation that virtually amputated their alienated limbs, allowing them to experience their ideal selves. During the exposure, both patients reported reductions in BIID-related complaints. These preliminary results suggest the existence of a possible therapeutic and diagnostic potential that AR possesses, which warrants further consideration within clinical healthcare settings.
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Affiliation(s)
- Collin Turbyne
- Psychiatry, Academic Medical Center, Amsterdam, Noord-Holland, The Netherlands
| | - Pelle de Koning
- Psychiatry, Academic Medical Center, Amsterdam, Noord-Holland, The Netherlands
| | - Jasper Zantvoord
- Psychiatry, Academic Medical Center, Amsterdam, Noord-Holland, The Netherlands
| | - Damiaan Denys
- Psychiatry, Academic Medical Center, Amsterdam, Noord-Holland, The Netherlands
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Behrens C, Friel P, Grocholewski A, Dombert E, Brühl A, Kasten E, Heinrichs N. [Cognitive and Affective Processes in Body Integrity Dysphoria (BID): A Pilot Study]. Psychother Psychosom Med Psychol 2020; 70:386-395. [PMID: 32162296 DOI: 10.1055/a-1099-9925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Individuals suffering from Body Integrity Dysphoria (BID) have the longstanding desire for amputation (BID-A) or palsy (BID-P). Most findings on mental aspects of BID are based on self-reports from sufferers. The aim of this pilot study is to examine cognitive and affective processes beyond what is accessible by self-reports. Therefore, n=5 BID-A, n=3 BID-P-sufferers, n=22 healthy controls and n=8 patients with body dysmorphic disorder (a further group with a strong desire for body modification) were tested. Selective attention bias (eye-tracking), tendency towards false memory (DRM-paradigm) and lack of affective involvement in the unwanted body part (induction and destruction of a rubber-hand/foot-illusion) were examined. Descriptive comparison of the groups showed that BID-A-sufferers fixated amputation stumps faster and longer than any other group and showed a reduced fear response when the body illusion was destroyed. There was no indication of a higher tendency towards false memory in either BID-group. Due to the small sample size, these results cannot be generalized. However, findings showed that BID-symptoms and underlying processes can be accessed in more ways than through self-reports. Moreover, results indicate that BID-A-sufferers selective attention and affective involvement differ from people not desiring an amputation. Understanding these processes may help developing an etiological model, identifying subtypes, and deriving treatment approaches.
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Saetta G, Hänggi J, Gandola M, Zapparoli L, Salvato G, Berlingeri M, Sberna M, Paulesu E, Bottini G, Brugger P. Neural Correlates of Body Integrity Dysphoria. Curr Biol 2020; 30:2191-2195.e3. [DOI: 10.1016/j.cub.2020.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 01/30/2023]
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Stone KD, Kornblad CAE, Engel MM, Dijkerman HC, Blom RM, Keizer A. Lower limb peripersonal space and the desire to amputate a leg. PSYCHOLOGICAL RESEARCH 2020; 85:1221-1233. [PMID: 32198609 PMCID: PMC8049934 DOI: 10.1007/s00426-020-01316-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 03/07/2020] [Indexed: 02/05/2023]
Abstract
Body integrity identity disorder (BIID) is a rare condition defined by a persistent desire to amputate or paralyze a healthy limb (usually one or both of the legs). This desire arises from experiencing a mismatch between the internal body model and the actual physical/functional boundaries of the body. People with BIID show an abnormal physiological response to stimuli approaching the affected (unwanted) but not the unaffected leg, which might suggest a retracted peripersonal space (PPS: a multisensory integration zone near the body) around the unwanted limb. Thus, using a visuo-tactile interaction task, we examined leg PPS in a group of healthy men and three men with BIID who desired unilateral leg amputation. PPS size (~ 70 cm) around the unwanted BIID legs did not differ from that of healthy controls. Although the leg feels foreign in BIID, it still seems to maintain a PPS, presumably to protect it and facilitate interactions within the surrounding environment.
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Affiliation(s)
- Kayla D Stone
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands.
| | - Clara A E Kornblad
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
| | - Manja M Engel
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
| | - H Chris Dijkerman
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
| | - Rianne M Blom
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anouk Keizer
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
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Stone KD, Kornblad CAE, Engel MM, Dijkerman HC, Blom RM, Keizer A. An Investigation of Lower Limb Representations Underlying Vision, Touch, and Proprioception in Body Integrity Identity Disorder. Front Psychiatry 2020; 11:15. [PMID: 32161554 PMCID: PMC7052367 DOI: 10.3389/fpsyt.2020.00015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 01/08/2020] [Indexed: 01/26/2023] Open
Abstract
Individuals with Body Integrity Identity Disorder (BIID) have a (non-psychotic) longstanding desire to amputate or paralyze one or more fully-functioning limbs, often the legs. This desire presumably arises from experiencing a mismatch between one's perceived mental image of the body and the physical structural and/or functional boundaries of the body itself. While neuroimaging studies suggest a disturbed body representation network in individuals with BIID, few behavioral studies have looked at the manifestation of this disrupted lower limb representations in this population. Specifically, people with BIID feel like they are overcomplete in their current body. Perhaps sensory input, processed normally on and about the limb, cannot communicate with a higher-order model of the leg in the brain (which might be underdeveloped). We asked individuals who desire paralysis or amputation of the lower legs (and a group of age- and sex-matched controls) to make explicit and implicit judgments about the size and shape of their legs while relying on vision, touch, and proprioception. We hypothesized that BIID participants would mis-estimate the size of their affected leg(s) more than the same leg of controls. Using a multiple single-case analysis, we found no global differences in lower limb representations between BIID participants and controls. Thus, while people with BIID feel that part of the body is foreign, they can still make normal sensory-guided implicit and explicit judgments about the limb. Moreover, these results suggest that BIID is not a body image disorder, per se, and that an examination of leg representation does not uncover the disturbed bodily experience that individuals with BIID have.
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Affiliation(s)
- Kayla D. Stone
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, Netherlands
| | - Clara A. E. Kornblad
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, Netherlands
| | - Manja M. Engel
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, Netherlands
| | - H. Chris Dijkerman
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, Netherlands
| | - Rianne M. Blom
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Anouk Keizer
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, Netherlands
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Stone KD, Dijkerman HC, Bekrater-Bodmann R, Keizer A. Mental rotation of feet in individuals with Body Integrity Identity Disorder, lower-limb amputees, and normally-limbed controls. PLoS One 2019; 14:e0221105. [PMID: 31419248 PMCID: PMC6697338 DOI: 10.1371/journal.pone.0221105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/30/2019] [Indexed: 01/28/2023] Open
Abstract
Body Integrity Identity Disorder (BIID) is a non-psychotic condition wherein individuals desire amputation or paralysis of one or more healthy, fully-functioning limbs (predominantly the legs). Individuals with BIID have been suggested to have a mismatch between the perceived mental representation of the body and its actual physical structure, such that their desired identity matches that of a lower-limb amputee. Accordingly, studies have reported an altered central network involving body representation of the legs in BIID, but its relationship to behavior remains unclear. In the present study, we investigated the integrity of body representation in individuals with BIID, acquired lower-limb amputees, and normally-limbed controls using an online mental rotation task. Participants judged the laterality of left and right foot images presented from different views, orientations, and of different types. We expected BIID participants to be slower for mentally rotating images that corresponded to their affected legs than lower-limb amputees and normally-limbed participants. We found that the groups did not significantly differ in their performance. All participants were slower at judging feet presented in awkward postures than natural postures, replicating previous studies and validating our online paradigm. The results are discussed in terms of the robust nature of visual and sensorimotor lower-limb representations, whether related to the self or as prototype, in the context of disturbed lower-limb integrity.
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Affiliation(s)
- Kayla D Stone
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands
| | - H Chris Dijkerman
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands
| | - Robin Bekrater-Bodmann
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anouk Keizer
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands
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Kohrman SI, Rustad JK, Suhail-Sindhu T, Fortney TA, Ramkumar DB, Warhold LG, Thakur D, Finn CT, Stern TA. Self-inflicted Limb Amputation: A Case of Nonparaphilic, Nonpsychotic Xenomelia. PSYCHOSOMATICS 2019; 61:70-75. [PMID: 31053421 DOI: 10.1016/j.psym.2019.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Samuel I Kohrman
- The Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH; Dartmouth-Hitchcock Adult Psychiatry Residency Program, Lebanon, NH.
| | - James K Rustad
- The Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH; Department of Mental Health and Behavioral Sciences, White River Junction VA Medical Center, White River Junction, VT
| | - Timur Suhail-Sindhu
- The Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH; Dartmouth-Hitchcock Adult Psychiatry Residency Program, Lebanon, NH; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI
| | - Thomas A Fortney
- The Department of Orthopedic Surgery, Geisel School of Medicine at Dartmouth, Lebanon, NH; Dartmouth Hitchcock Orthopedic Surgery Residency Program, Lebanon, NH
| | - Dipak B Ramkumar
- The Department of Orthopedic Surgery, Geisel School of Medicine at Dartmouth, Lebanon, NH; Dartmouth Hitchcock Orthopedic Surgery Residency Program, Lebanon, NH
| | - Lance G Warhold
- The Department of Orthopedic Surgery, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Devendra Thakur
- The Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Christine T Finn
- The Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Theodore A Stern
- The Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Reed GM, First MB, Kogan CS, Hyman SE, Gureje O, Gaebel W, Maj M, Stein DJ, Maercker A, Tyrer P, Claudino A, Garralda E, Salvador‐Carulla L, Ray R, Saunders JB, Dua T, Poznyak V, Medina‐Mora ME, Pike KM, Ayuso‐Mateos JL, Kanba S, Keeley JW, Khoury B, Krasnov VN, Kulygina M, Lovell AM, de Jesus Mari J, Maruta T, Matsumoto C, Rebello TJ, Roberts MC, Robles R, Sharan P, Zhao M, Jablensky A, Udomratn P, Rahimi‐Movaghar A, Rydelius P, Bährer‐Kohler S, Watts AD, Saxena S. Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry 2019; 18:3-19. [PMID: 30600616 PMCID: PMC6313247 DOI: 10.1002/wps.20611] [Citation(s) in RCA: 292] [Impact Index Per Article: 58.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders following ICD-11's approval. The development of the ICD-11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.
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Affiliation(s)
- Geoffrey M. Reed
- Department of Mental Health and Substance AbuseWorld Health OrganizationGenevaSwitzerland,Department of PsychiatryColumbia University Medical CenterNew YorkNYUSA
| | - Michael B. First
- Department of PsychiatryColumbia University Medical CenterNew YorkNYUSA,New York State Psychiatric InstituteNew YorkNYUSA
| | - Cary S. Kogan
- School of PsychologyUniversity of OttawaOttawaONCanada
| | - Steven E. Hyman
- Stanley Center for Psychiatric ResearchBroad Institute of Harvard and Massachusetts Institute of TechnologyCambridgeMAUSA
| | - Oye Gureje
- Department of PsychiatryUniversity of IbadanIbadanNigeria
| | - Wolfgang Gaebel
- Department of Psychiatry and Psychotherapy, Medical FacultyHeinrich‐Heine UniversityDüsseldorfGermany
| | - Mario Maj
- Department of PsychiatryUniversity of Campania “L. Vanvitelli”NaplesItaly
| | - Dan J. Stein
- Department of PsychiatryUniversity of Cape Town, and South African Medical Research Council Unit on Risk and Resilience in Mental DisordersCape TownSouth Africa
| | | | - Peter Tyrer
- Centre for Mental HealthImperial CollegeLondonUK
| | - Angelica Claudino
- Department of PsychiatryUniversidade Federal de São Paulo (UNIFESP/EPM)São PauloBrazil
| | | | - Luis Salvador‐Carulla
- Research School of Population HealthAustralian National UniversityCanberraACTAustralia
| | - Rajat Ray
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - John B. Saunders
- Centre for Youth Substance Abuse ResearchUniversity of QueenslandBrisbaneQLDAustralia
| | - Tarun Dua
- Department of Mental Health and Substance AbuseWorld Health OrganizationGenevaSwitzerland
| | - Vladimir Poznyak
- Department of Mental Health and Substance AbuseWorld Health OrganizationGenevaSwitzerland
| | | | - Kathleen M. Pike
- Department of PsychiatryColumbia University Medical CenterNew YorkNYUSA
| | - José L. Ayuso‐Mateos
- Department of PsychiatryUniversidad Autonoma de Madrid; Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM); Instituto de Investigación Sanitaria La PrincesaMadridSpain
| | | | - Jared W. Keeley
- Department of PsychologyVirginia Commonwealth UniversityRichmondVAUSA
| | - Brigitte Khoury
- Department of PsychiatryAmerican University of Beirut Medical CenterBeirutLebanon
| | - Valery N. Krasnov
- Moscow Research Institute of PsychiatryNational Medical Research Centre for Psychiatry and NarcologyMoscowRussian Federation
| | - Maya Kulygina
- Moscow Research Institute of PsychiatryNational Medical Research Centre for Psychiatry and NarcologyMoscowRussian Federation
| | - Anne M. Lovell
- Institut National de la Santé et de la Recherche Médicale U988ParisFrance
| | - Jair de Jesus Mari
- Department of PsychiatryUniversidade Federal de São Paulo (UNIFESP/EPM)São PauloBrazil
| | | | | | - Tahilia J. Rebello
- Department of PsychiatryColumbia University Medical CenterNew YorkNYUSA,New York State Psychiatric InstituteNew YorkNYUSA
| | - Michael C. Roberts
- Office of Graduate Studies and Clinical Child Psychology ProgramUniversity of KansasLawrenceKSUSA
| | - Rebeca Robles
- National Institute of Psychiatry Ramón de la Fuente MuñizMexico CityMexico
| | - Pratap Sharan
- Department of PsychiatryAll India Institute of Medical SciencesNew DelhiIndia
| | - Min Zhao
- Shanghai Mental Health Center and Department of PsychiatryShanghai Jiao Tong University School of MedicineShanghaiPeople's Republic of China
| | - Assen Jablensky
- Centre for Clinical Research in NeuropsychiatryUniversity of Western AustraliaPerthWAAustralia
| | - Pichet Udomratn
- Department of PsychiatryPrince of Songkla UniversityHat YaiThailand
| | - Afarin Rahimi‐Movaghar
- Iranian National Center for Addiction Studies, Tehran University of Medical SciencesTehranIran
| | - Per‐Anders Rydelius
- Department of Child and Adolescent PsychiatryKarolinska InstituteStockholmSweden
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Barrow E, Oyebode F. Body integrity identity disorder: clinical features and ethical dimensions. BJPSYCH ADVANCES 2018. [DOI: 10.1192/bja.2018.55] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARYBody integrity identity disorder (BIID) is a rare and complex identity disorder described by the desire to acquire a physical disability and an associated sense of incompleteness at being able-bodied. Individuals with the disorder often delay presentation until later in life because of perceived stigma about wishing to acquire a physical disability, and may have sought amputation already through ‘underground’ means or self-harm (attempts at self-amputation). In this article we present an account of the recent history and origins of the disorder, from its early descriptions and case reports through to the current neuropsychiatric theory of right superior parietal lobe dysfunction as basis for the disorder. We consider the epidemiology, pathogenesis and clinical features of this identity disorder of bodily integrity, highlighting the associations with conditions such as gender identity disorder. With this we then discuss the ethical considerations for available treatment options, mainly elective surgical amputation.LEARNING OBJECTIVES•Understand the current definition and clinical features of body integrity identity disorder•Be familiar with the conceptual history of the disorder, epidemiology and current neuropsychiatric perspective•Be aware of the ethical aspects of elective surgical amputation as a treatment for the disorderDECLARATION OF INTERESTNone.
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Mental Images in Body Integrity Identity Disorder (BIID) and in Body Dysmorphic Disorder (BDD): An Exploratory Study. BEHAVIOUR CHANGE 2018. [DOI: 10.1017/bec.2018.17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractLittle is known about mental images (cognitive representations with sensory qualities) in body integrity identity disorder (BIID). This study aimed to determine whether individuals with BIID experience mental images and, if so, whether they differ to those experienced by individuals with body dysmorphic disorder (BDD) and healthy controls. A semi-structured interview on mental images and their qualities was delivered to a sample of 22 individuals with BIID and 19 with BDD, and 22 healthy controls. Both the BIID (n = 15, 68.2%) and BDD (n = 14, 73.7%) groups reported significantly more mental images than healthy controls (n = 3, 13.6%), but no differences between the two clinical groups were found. While mental images in BDD were focused on ‘flawed’ body parts, images in BIID involved the desired handicap. Mental images in BIID were experienced as less distressing and more sexually arousing compared to BDD. No further differences were found between the groups (e.g., regarding sensory multimodality, dominance of a specific body part). Although the two groups reported a similar frequency of mental images, images appear to serve different functions across conditions. Clinically, it may be necessary to target the positive mental images in BIID to improve treatment outcome.
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Stone KD, Bullock F, Keizer A, Dijkerman HC. The disappearing limb trick and the role of sensory suggestibility in illusion experience. Neuropsychologia 2018; 117:418-427. [DOI: 10.1016/j.neuropsychologia.2018.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 12/13/2022]
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Oddo-Sommerfeld S, Hänggi J, Coletta L, Skoruppa S, Thiel A, Stirn AV. Brain activity elicited by viewing pictures of the own virtually amputated body predicts xenomelia. Neuropsychologia 2018; 108:135-146. [DOI: 10.1016/j.neuropsychologia.2017.11.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 10/29/2017] [Accepted: 11/20/2017] [Indexed: 12/11/2022]
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Hänggi J, Vitacco DA, Hilti LM, Luechinger R, Kraemer B, Brugger P. Structural and functional hyperconnectivity within the sensorimotor system in xenomelia. Brain Behav 2017; 7:e00657. [PMID: 28293484 PMCID: PMC5346531 DOI: 10.1002/brb3.657] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 01/06/2017] [Accepted: 01/11/2017] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Xenomelia is a rare condition characterized by the persistent and compulsive desire for the amputation of one or more physically healthy limbs. We highlight the neurological underpinnings of xenomelia by assessing structural and functional connectivity by means of whole-brain connectome and network analyses of regions previously implicated in empirical research in this condition. METHODS We compared structural and functional connectivity between 13 xenomelic men with matched controls using diffusion tensor imaging combined with fiber tractography and resting state functional magnetic resonance imaging. Altered connectivity in xenomelia within the sensorimotor system has been predicted. RESULTS We found subnetworks showing structural and functional hyperconnectivity in xenomelia compared with controls. These subnetworks were lateralized to the right hemisphere and mainly comprised by nodes belonging to the sensorimotor system. In the connectome analyses, the paracentral lobule, supplementary motor area, postcentral gyrus, basal ganglia, and the cerebellum were hyperconnected to each other, whereas in the xenomelia-specific network analyses, hyperconnected nodes have been found in the superior parietal lobule, primary and secondary somatosensory cortex, premotor cortex, basal ganglia, thalamus, and insula. CONCLUSIONS Our study provides empirical evidence of structural and functional hyperconnectivity within the sensorimotor system including those regions that are core for the reconstruction of a coherent body image. Aberrant connectivity is a common response to focal neurological damage. As exemplified here, it may affect different brain regions differentially. Due to the small sample size, our findings must be interpreted cautiously and future studies are needed to elucidate potential associations between hyperconnectivity and limb disownership reported in xenomelia.
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Affiliation(s)
- Jürgen Hänggi
- Division Neuropsychology Department of Psychology University of Zurich Zurich Switzerland
| | - Deborah A Vitacco
- Neuropsychology Unit Department of Neurology University Hospital Zurich Zurich Switzerland
| | - Leonie M Hilti
- Neuropsychology Unit Department of Neurology University Hospital Zurich Zurich Switzerland
| | - Roger Luechinger
- Institute for Biomedical Engineering University and ETH Zurich Zurich Switzerland
| | - Bernd Kraemer
- Psychiatric Services Hospitals of the Canton of Solothurn Olten Switzerland
| | - Peter Brugger
- Neuropsychology Unit Department of Neurology University Hospital Zurich Zurich Switzerland; Center for Integrative Human Physiology (ZIHP) University of Zurich Zurich Switzerland
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Brugger P, Christen M, Jellestad L, Hänggi J. Limb amputation and other disability desires as a medical condition. Lancet Psychiatry 2016; 3:1176-1186. [PMID: 27889011 DOI: 10.1016/s2215-0366(16)30265-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 08/15/2016] [Accepted: 08/15/2016] [Indexed: 10/20/2022]
Abstract
Some people have a profound dissatisfaction with what is considered an able-bodied state by most others. These individuals desire to be disabled, by conventional standards. In this Review, we integrate research findings about the desire for a major limb amputation or paralysis (xenomelia). Neuropsychological and neuroimaging explorations of xenomelia show functional and structural abnormalities in predominantly right hemisphere cortical circuits of higher-order bodily representation, including affective and sexual aspects of corporeal awareness. These neural underpinnings of xenomelia do not necessarily imply a neurological cause, and a full understanding of the condition requires consideration of the interface between neural and social contributions to the bodily self and the concept of disability. Irrespective of cause, disability desires are accompanied by a disabling bodily dysphoria, in many respects similar to gender dysphoria, and we suggest that they should be considered a mental disorder.
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Affiliation(s)
- Peter Brugger
- Neuropsychology Unit, Department of Neurology, University Hospital Zurich, Zurich, Switzerland; Center for Integrative Human Physiology (ZIHP), University of Zurich, Zurich, Switzerland; Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland.
| | - Markus Christen
- University Research Priority Program Ethics, University of Zurich, Zurich, Switzerland
| | - Lena Jellestad
- Department of Psychiatry and Psychotherapy, University Hospital Zurich, Zurich, Switzerland
| | - Jürgen Hänggi
- Division of Neuropsychology, Department of Psychology, University of Zurich, Zurich, Switzerland
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28
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Blom RM, van Wingen GA, van der Wal SJ, Luigjes J, van Dijk MT, Scholte HS, Denys D. The Desire for Amputation or Paralyzation: Evidence for Structural Brain Anomalies in Body Integrity Identity Disorder (BIID). PLoS One 2016; 11:e0165789. [PMID: 27832097 PMCID: PMC5104450 DOI: 10.1371/journal.pone.0165789] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 10/06/2016] [Indexed: 12/04/2022] Open
Abstract
Background Body Integrity Identity Disorder (BIID) is a condition in which individuals perceive a mismatch between their internal body scheme and physical body shape, resulting in an absolute desire to be either amputated or paralyzed. The condition is hypothesized to be of congenital nature, but evidence for a neuro-anatomical basis is sparse. Methods We collected T1-weighted structural magnetic resonance imaging scans on a 3T scanner in eight individuals with BIID and 24 matched healthy controls, and analyzed the data using voxel-based morphometry. Results The results showed reduced grey matter volume in the left dorsal and ventral premotor cortices and larger grey matter volume in the cerebellum (lobule VIIa) in individuals with BIID compared to controls. Conclusion The premotor cortex and cerebellum are thought to be crucial for the experience of body-ownership and the integration of multisensory information. Our results suggest that BIID is associated with structural brain anomalies and might result from a dysfunction in the integration of multisensory information, leading to the feeling of disunity between the mental and physical body shape.
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Affiliation(s)
- Rianne M. Blom
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- * E-mail:
| | - Guido A. van Wingen
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Brain Imaging Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sija J. van der Wal
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Judy Luigjes
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Brain Imaging Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Milenna T. van Dijk
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Sackler Institute of Graduate Biomedical Sciences, New York University School of Medicine, New York, NY, United States of America
| | - H. Steven Scholte
- Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Damiaan Denys
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Brain Imaging Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Netherlands Institute for Neuroscience, an institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
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Hänggi J, Bellwald D, Brugger P. Shape alterations of basal ganglia and thalamus in xenomelia. Neuroimage Clin 2016; 11:760-769. [PMID: 27330976 PMCID: PMC4909827 DOI: 10.1016/j.nicl.2016.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 05/06/2016] [Accepted: 05/27/2016] [Indexed: 12/21/2022]
Abstract
Xenomelia is a rare condition characterized by the persistent desire for the amputation of physically healthy limbs. Associations with morphological alterations such as reduced cortical thickness and surface area. Nothing is known, however, about the potential involvement of subcortical structures. The thalamus and basal ganglia process, relay, and integrate sensorimotor information and are involved in the preparation and execution of movements. Moreover, both of these structures house somatotopic representations of all body parts. We therefore investigated subcortical correlates of xenomelia by assessing basal ganglia and thalamus by means of vertex-wise shape analyses. For that purpose, we compared the shape of the thalamus, putamen, caudate nucleus, and the pallidum in 13 men suffering from xenomelia, all desiring a leg amputation, compared to 13 healthy control men. We hypothesised that the target leg is misrepresented in subcortical structures of individuals with xenomelia, especially in locations with a somatotopic representation. Shape analyses showed thinning of bilateral dorsomedial putamina, left ventromedial caudate nucleus and left medial pallidum associated with xenomelia. This was accompanied by thickening of bilateral lateral pallida and the left frontolateral thalamus. These shape differences were mainly located in sensorimotor areas of somatotopic leg representations. The present study provides strong evidence for shape differences in striatal, pallidal, and thalamic subregions housing subcortical body part representations. It adds to previously described neural correlates of a condition one can barely empathize with and invites future connectivity analyses in cortico-subcortical networks.
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Affiliation(s)
- Jürgen Hänggi
- Division Neuropsychology, Department of Psychology, University of Zurich, Switzerland.
| | - Dorian Bellwald
- Division Neuropsychology, Department of Psychology, University of Zurich, Switzerland
| | - Peter Brugger
- Neuropsychology Unit, Department of Neurology, University Hospital Zurich, Switzerland; Center for Integrative Human Physiology (ZIHP), University of Zurich, Switzerland.
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Blom RM, Vulink NC, van der Wal SJ, Nakamae T, Tan Z, Derks EM, Denys D. Body integrity identity disorder crosses culture: case reports in the Japanese and Chinese literature. Neuropsychiatr Dis Treat 2016; 12:1419-23. [PMID: 27366074 PMCID: PMC4913986 DOI: 10.2147/ndt.s102932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Body integrity identity disorder (BIID) is a condition in which people do not perceive a part of their body as their own, which results in a strong desire for amputation or paralyzation. The disorder is likely to be congenital due to its very early onset. The English literature describes only Western patients with BIID, suggesting that the disorder might be merely prevalent in the West. To scrutinize this assumption, and to extend our knowledge of the etiology of BIID, it is important to trace cases with BIID in non-Western populations. Our objective was to review Chinese and Japanese literature on BIID to learn about its presence in populations with a different genetic background. A systematic literature search was performed in databases containing Japanese and Chinese research, published in the respective languages. Five Japanese articles of BIID were identified which described two cases of BIID, whereas in the Chinese databases only BIID-related conditions were found. This article reports some preliminary evidence that BIID is also present in non-Western countries. However, making general statements about the biological background of the disorder is hampered by the extremely low number of cases found. This low number possibly resulted from the extreme secrecy associated with the disorder, perhaps even more so in Asian countries.
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Affiliation(s)
- Rianne M Blom
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Nienke C Vulink
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Sija J van der Wal
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Takashi Nakamae
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neural Computation for Decision-Making, ATR Brain Information Communication Research Laboratory Group, Kyoto, Japan
| | - Zhonglin Tan
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Psychiatry, Hangzhou Mental Health Center, Hangzhou, People's Republic of China
| | - Eske M Derks
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Damiaan Denys
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences, Amsterdam, the Netherlands
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Bottini G, Brugger P, Sedda A. Is the desire for amputation related to disturbed emotion processing? A multiple case study analysis in BIID. Neurocase 2015; 21:394-402. [PMID: 24679146 DOI: 10.1080/13554794.2014.902969] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Body integrity identity disorder (BIID) is characterized by the overwhelming desire to amputate one or more healthy limbs or to be paraplegic. Recently, a neurological explanation of this condition has been proposed, in part on the basis of findings that the insular cortex might present structural anomalies in these individuals. While these studies focused on body representation, much less is known about emotional processing. Importantly, emotional impairments have been found in psychiatric disorders, and a psychiatric etiology is still a valid alternative to purely neurological accounts of BIID. In this study, we explored, by means of a computerized experiment, facial emotion recognition and emotional responses to disgusting images in seven individuals with BIID, taking into account their clinical features and investigating in detail disgust processing, strongly linked to insular functioning. We demonstrate that BIID is not characterized by a general emotional impairment; rather, there is a selectively reduced disgust response to violations of the body envelope. Taken together, our results support the need to explore this condition under an interdisciplinary perspective, taking into account also emotional connotations and the social modulation of body representation.
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Affiliation(s)
- Gabriella Bottini
- a Department of Brain and Behavioral Science , University of Pavia , Pavia , Italy
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Garcia-Falgueras A. Gender Dysphoria and Body Integrity Identity Disorder: Similarities and Differences. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/psych.2014.52025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sedda A, Bottini G. Apotemnophilia, body integrity identity disorder or xenomelia? Psychiatric and neurologic etiologies face each other. Neuropsychiatr Dis Treat 2014; 10:1255-65. [PMID: 25045269 PMCID: PMC4094630 DOI: 10.2147/ndt.s53385] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This review summarizes the available studies of a rare condition in which individuals seek the amputation of a healthy limb or desire to be paraplegic. Since 1977, case reports and group studies have been produced, trying to understand the cause of this unusual desire. The main etiological hypotheses are presented, from the psychological/psychiatric to the most recent neurologic explanation. The paradigms adopted and the clinical features are compared across studies and analyzed in detail. Finally, future directions and ethical implications are discussed. A proposal is made to adopt a multidisciplinary approach that comprises state-of-the-art technologies and a variety of theoretical models, including both body representation and psychological and sexual components.
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Affiliation(s)
- Anna Sedda
- Department of Behavioral and Brain Sciences, University of Pavia, Pavia, Italy ; Cognitive Neuropsychology Laboratory, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Gabriella Bottini
- Department of Behavioral and Brain Sciences, University of Pavia, Pavia, Italy ; Cognitive Neuropsychology Laboratory, Niguarda Ca' Granda Hospital, Milan, Italy
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Brugger P, Lenggenhager B, Giummarra MJ. Xenomelia: a social neuroscience view of altered bodily self-consciousness. Front Psychol 2013; 4:204. [PMID: 23630513 PMCID: PMC3634160 DOI: 10.3389/fpsyg.2013.00204] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 04/02/2013] [Indexed: 11/22/2022] Open
Abstract
Xenomelia, the “foreign limb syndrome,” is characterized by the non-acceptance of one or more of one’s own extremities and the resulting desire for elective limb amputation or paralysis. Formerly labeled “body integrity identity disorder” (BIID), the condition was originally considered a psychological or psychiatric disorder, but a brain-centered Zeitgeist and a rapidly growing interest in the neural underpinnings of bodily self-consciousness has shifted the focus toward dysfunctional central nervous system circuits. The present article outlays both mind-based and brain-based views highlighting their shortcomings. We propose that full insight into what should be conceived a “xenomelia spectrum disorder” will require interpretation of individual symptomatology in a social context. A proper social neuroscience of xenomelia respects the functional neuroanatomy of corporeal awareness, but also acknowledges the brain’s plasticity in response to an individual’s history, which is lived against a cultural background. This integrated view of xenomelia will promote the subfield of consciousness research concerned with the unity of body and self.
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Affiliation(s)
- Peter Brugger
- Neuropsychology Unit, Department of Neurology, University Hospital Zurich Zurich, Switzerland ; Zurich Center for Integrative Human Physiology, University of Zurich Zurich, Switzerland ; Neuroscience Center Zurich, University of Zurich and ETH Zurich Zurich, Switzerland
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Hilti LM, Hänggi J, Vitacco DA, Kraemer B, Palla A, Luechinger R, Jäncke L, Brugger P. The desire for healthy limb amputation: structural brain correlates and clinical features of xenomelia. Brain 2012; 136:318-29. [DOI: 10.1093/brain/aws316] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Abstract
Introduction Body Integrity Identity Disorder (BIID) is a rare, infrequently studied and highly secretive condition in which there is a mismatch between the mental body image and the physical body. Subjects suffering from BIID have an intense desire to amputate a major limb or severe the spinal cord in order to become paralyzed. Aim of the study is to broaden the knowledge of BIID amongst medical professionals, by describing all who deal with BIID. Methods Somatic, psychiatric and BIID characteristic data were collected from 54 BIID individuals using a detailed questionnaire. Subsequently, data of different subtypes of BIID (i.e. wish for amputation or paralyzation) were evaluated. Finally, disruption in work, social and family life due to BIID in subjects with and without amputation were compared. Results Based on the subjects' reports we found that BIID has an onset in early childhood. The main rationale given for their desire for body modification is to feel complete or to feel satisfied inside. Somatic and severe psychiatric co-morbidity is unusual, but depressive symptoms and mood disorders can be present, possibly secondary to the enormous distress BIID puts upon a person. Amputation and paralyzation variant do not differ in any clinical variable. Surgery is found helpful in all subjects who underwent amputation and those subjects score significantly lower on a disability scale than BIID subjects without body modification. Conclusions The amputation variant and paralyzation variant of BIID are to be considered as one of the same condition. Amputation of the healthy body part appears to result in remission of BIID and an impressive improvement of quality of life. Knowledge of and respect for the desires of BIID individuals are the first steps in providing care and may decrease the huge burden they experience.
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Affiliation(s)
- Rianne M. Blom
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Raoul C. Hennekam
- Departments of Paediatrics and Translational Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Damiaan Denys
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- The Netherlands Institute for Neuroscience, an institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
- * E-mail:
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