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Apotemnophilia is a neurological disorder in which otherwise sane and rational individuals express a strong and specific desire for the amputation of a healthy limb or limbs. It is due to hypothesized damage to the right parietal lobe, as the disorder has features in common with somatoparaphrenia. When experienced very strongly, some people with apotemnophilia come to feel discontented with their bodies and want to actually remove an otherwise healthy limb, a condition called body integrity identity disorder. Some apotemnophiles seek surgeons to perform an amputation or purposefully injure a limb in order to force emergency medical amputation. A separate, though occasionally comorbid, definition of Apotemnophilia is erotic interest in being or looking like an amputee. This separate definition should not be confused with acrotomophilia, which is the erotic interest in people who are amputees.

Definition

A paraphilia of the stigmatic/eligibilic type in which sexuerotic arousal and facilitation or attainment of orgasm and dependent upon oneself being an amputee . In this disorder, otherwise sane and rational individuals express a strong and specific desire for the amputation of a healthy limb or limbs. Most date this desire to their childhood and not uncommonly the sufferer will attempt to obtain amputation of the specific limb. As few surgeons are willing to amputate healthy limbs, this often means that the patient themselves will attempt to irrevocably damage the limb in question, thus necessitating formal amputation. After amputation most report to being happy with their decision and often state, paradoxically, that they are ‘complete’ at last

Classifications

Patients diagnosed with Apotemnophilia are sometimes classified as being patients of Body Integrity Identity Disorder (BIID). Apotemnophilia is usually classified under BIID becuase patients feel discontented with their bodies and want to remove an otherwise healthy limb. An apotemnophile becomes fixated on carrying out a self-contrived amputation, or obtaining one in a hospital. Until recently, any desire for amputation was classified as this "disorder", but recently, the psychiatric community has begun to differentiate between this condition and Body Integrity Identity Disorder, in which an individual desires an amputation without an accompanying sexual component to this desire.

An individual with true apotemnophilia may be chronically unsatisfied with their sexual relationships, or even completely sexually disfunctional until their desire for amputation is realized. Apotemnophilia condition is similar to Acrotomophilia but is differentiated by the desire for oneself to be an amputee as oposed to one's partner having an amputation.

BIID

Patients with Body Integrity Identity Disorder(BIID) typically desire to have one more limbs amputated from their bodies. Today, there are no specific causes of BIDD. There have been multiple theories behind the cause of BIID and why some people suffer from this illness. One theory states that a child adopts this body image of being an amputee which results in the development of wanting the body from a young age – this has been seen in the majority of apotemnophiles. Another theory suggests that a child who feels unloved may believe that becoming an amputee will bring attention, love and sympathy. BIID is a neuro-psychological condition where there is an difference in the cerebral cortex relating to the connection between the brain and the limbs. If the condition was neurological, it is conceptualized as a form of somatoparaphrenia, a condition that often follows a stroke afflicting the parietal lobe. It has been seen through recent studies that most patients with BIID happen to be males. Reasons for this is because the right side of the inferior-parietal lobule is significantly smaller in men than women. This malfunction explains the reason as to why one sex is more prone to BIID than another sex. It has also been seen that requests for amputations are most often on the left-side of the body than the right side. The right side of the brain is known for controlling the left side and the left side of the brain is known for controlling the right side. Damage to the right side of the inferior-parietal lobule contributes to the desire of patients wanting to amputate the left side of the body.

Acrotomophilia

Acrotomophilia (from the Greek akron , tomein and philein ), is a paraphilia in which an individual expresses strong sexual interest in amputees. It is a counterpart to apotemnophilia, the sexual interest in being an amputee.

Amputee fetishism has been described as a form of abuse levelled at the relative vulnerability and dependence of disabled women.

Signs and Symptoms

Depression

Apotemnophiles will become prone to extreme levels of depression caused by isolation, confusion and the inability to determine what they're supposed to be like physically and emotionally. Patients with apotemnophilia will feel that they are apart from the norm and will isolate themselves from socializing.

Intentional injuries

Caused by desperate attempts to get the unwanted limbs to be amputated. People with apotemnophilia have a longterm vision of their body as missing limbs. Originally developed at a young age, apotemnophiles will go through drastic measures to ensure that their lifelong dream of being an amputee is fulfilled. Mentioned below, apotemnophiles will purposely induce infections into limbs or even harm themselves by going as far as sawing off limbs half way so medical professionals do not have a choice other than to remove the limb.

Causes

There are no direct causes of apotemnophilia. However, recent medical research has shown that apotemnophilia has been linked to abnormalities in the prefrontal cortex. Aside from apotenmophilia, philias alone have no direct causes that are known today. Phobias however, are known to be caused by three main things which may contribute to philias as well. Genetics: Research has shown that certain phobias may run in families. For example, twins who are raised separately, in different locations, may develop the same phobias. However, many people with phobias have no relatives with the condition. Cultural Factors: Some phobias occur only in certain cultural groups. An example is taijin kyofusho, a social phobia that appears almost exclusively in Japan. This is a fear of offending or harming others in social situations. It is markedly different from a traditional social phobia, in which the sufferer is afraid of being personally embarrassed on humiliated. It is therefore possible that culture plays some role in phobia development. Life Experience: Many phobias are based in real-life events that may or may not be consciously remembered. A phobia of dogs, for example, may stem from being attacked as a small child. A social phobia may develop from teenage awkwardness or childhood bullying.

It is likely that a combination of these factors must be in place for a phobia to develop. However, more research is necessary before a definitive conclusion can be reached.

Apotenmophilies have shown similarities in traits concerning the desire for amputation at a young age due to life experience. Therefore, life experience may play a greater role in the cause of apotemnophilia than cultural factors or genetics.

Pathophysiology

Pathology

Apotemnophilia has been medically correlated to abnormalities within the prefrontal cortex of the brain.

The prefrontal cortex is responsible for forming ideal body images that we see of ourselves. People with apotemnophilia have a body image in their brains of themselves missing limbs whether they are arms, legs or fingers. With this image, apotemnophiles believe that they are supposed to be living a life with amputated limbs. Without amputation, apotemnophiles feel that they are not living their lives like they are supposed to be resulting in increased depression, and identity crisis. Derived from Misplaced Pages article "Prefrontal Cortex": " Shimamura proposed Dynamic Filtering Theory to describe the role of the prefrontal cortex in executive functions. The prefrontal cortex is presumed to act as a high-level gating or filtering mechanism that enhances goal-directed activations and inhibits irrelevant activations. This filtering mechanism enables executive control at various levels of processing, including selecting, maintaining, updating, and rerouting activations. It has also been used to explain emotional regulation. theorize that "cognitive control stems from the active maintenance of patterns of activity in the prefrontal cortex that represents goals and means to achieve them. They provide bias signals to other brain structures whose net effect is to guide the flow of activity along neural pathways that establish the proper mappings between inputs, internal states, and outputs needed to perform a given task". Essentially the two theorize that the prefrontal cortex guides the inputs and connections which allows for cognitive control of our actions.

Implications can explain how much of a role the PFC has in guiding control of cognitive actions. In the researchers own words they claim that “depending on their target of influence, representations in the PFC can function variously as attentional templates, rules, or goals by providing top-down bias signals to other parts of the brain that guide the flow of activity along the pathways needed to perform a task”."

Physiology

There are very few studies related to the physiology associated with apotemnophilia. Currently there are no true understandings behind the physiology of apotemnophilia.

Psychological

Apotemnophilia has also been related to psychological characteristics. For example, apotemnophilia has been frequently compared to transvestitism along with the desire for sex changes or people with different sexual preferences. Although psychological classification has not been scientifically tested, it has been compared to the confusion a patient may experience while being diagnosed and treated with apotemnophilia. This confusion is similar to the confusion people may feel when they develop the desire to become one sex over another or change their preference in sexual attraction. Whether apotemnophilia is neurological or psychological, is still a debate in the medical and psychology community.

Sexual motivation

Sexual desires

Apotemnophilia has frequently been connected to sexual desires. Apotemnophilia has been connected to sexual desire for a number of years, but it is important not to confuse apotemnophilia with acrotomophilia. One excerpt from a case study from the American Journal of Psychotherapy by titled A case of apotemnophilia: a handicap as sexual preference by Dr. Walter Everaerd, PhD. from Utrecht, The Netherlands interviews an apotemnophile who describes his development of sexual preference:

"He became attracted to amputation in his 10th year. An amputated boy is according to him happier than he himself... When he was about 11 year old, he thought that he would be happier with an amputated leg. He therefore tried to infect sores on his leg. No infections developed at the time. After that he did not make any more attempts. He feels the he would not be able to bear the pain resulting from it... In addition he has photos and drawings of amputated boys and men, war victims, at his disposal. He fantasizes a lot about these photos. The image of amputation takes on erotic importance. When masturbating, amputated boys and men play at the role of partner in his fantasies. He is often occupied with self-amputation or the amputation of possible partners. He fantasizes for example, that a group of young boys who were playing together erected a guillotine. They chopped off each others legs. He does not find his desire for amputated partners and his fantasies about amputation sadistic. He often reacts astonished when I ask him that. It is not the amputation itself that is important but rather the result of it. In the development of this preference alloapotemnophilia and autoapotemnophilia were established. Now amputation of his own leg has no longer an sexual meaning. He says now that he only could feel complete once his leg has been amputated. Wanting to be amputated plays an important role in his sense of identity." Sexual desires from a life experience at a young age can be connected to one of the causes of apotemnophilia.

Management

Apotemnophiles are usually normal in terms of psychologically and have been proven to be emotionally healthy. However, due to its connections to being neurological, treatments are available to apotemnophiles. The major problem in providing treatment is that most apotemnophiles do not seek professional treatment for their condition. They are more likely to be found in the act of self amputation before actively seeking medical attention themselves. As mentioned in the article "I am in Depression", "One of the most prominent problems in the treatment of this disorder is that most apotemnophiles do not seek professional treatment for the condition, but rather receive it only when they have been caught in the act, referred by a surgeon they approached for getting an amputation or on the request of their sexual partner. Thus, their motivations for change may often stem from a desire to do it for someone else rather than from a genuine desire to change".

Cognitive and Behavioral Elements

Treatments for apotemnophiles have been studied; however, the two main forms of treatment seem to be a combination of cognitive and behavior elements that have been scientifically modified to change patterns of behavior and fetishes. These combinational therapy have significantly shown that there are reduced rates of recidivism than seen in untreated individuals.

Aversion Therapy

Along with a combinational treatment of cognitive and behavioral focuses, another element that has been studied is something known as aversion therapy. The therapy provides aversive conditioning to deviant sexual fantasies. Therapies are provided by medical attention and have shown to reduce the effects of apotemnophiles. Along with therapy, apotemnophiles will be exposed to treatment that focuses on cognitive behavioral programs that include training in social skills that may help maintain the deviant sexual arousal and behavioral patterns.

Ethics

Surgeons are placed in a difficult situation when apotemnophiles confront them about their situation. A surgeon or a medical professional will have to make the decision between amputating a perfectly normal limb or making his or her patients happy. Whether the medical professional performs this surgery has not been defined as "allowed" or "disallowed". Although many professionals will agree that a patient's happiness is primarily important, amputating a limb may be out of the question because there is nothing medically wrong with the limb itself.

Research Directions

Apotemnophilia has been studied for a number of years to determine whether this disorder is actually neurological or psychological. However, indepth research related to apotemnophilia and its correlation to the mind and body are still not clear. Recent research has shown small breakthroughs such that apotemnophiles are three times more likely to want removal of a left limb than right, in accordance with damage to the right parietal lobe, and also in concordance with sufferers of somatoparaphrenia; in addition, skin conductance response is significantly different above and below the line of desired amputation, and the line of desired amputation remains stable over time, with the desire often beginning in early childhood . Among a convenience sample of 52 apotemnophiles recruited from internet groups, the great majority wanted a single leg removed, cut above the knee. There are parallels between apotemnophilia as a motivation for body integrity identity disorder and autogynephilia as a motivation for some cases of male-to-female gender identity disorder.

There have been a number of studies to determine whether Apotemnophilia is a form of neurological disorder or a psychological disorder. It has been connected to activity in the prefrontal cortex while also being connected to the same concept of a person wanting to become a transvestite. Whether it is neurological or psychological, there will always be questions from both sides.

One study by Brang and his team helped scientifically back his hypothesis that apotemnophilia is a neurological disorder. His findings provide psychophysiological evidence to support our hypothesis that apotemnophilia arises from a congenital dysfunction of the right parietal lobe and, in particular the right superior parietal lobule, which receives and integrates input from various sensory areas and the insula to form a coherent sense of body image.

Apotemnophilia studies have frequently been run using skin conductance tests. The reason why skin conductance was used in this test was because it is a good indicator of general sympathetic arousal.

Recently, Brang proposed that the failure of a congenitally dysfunctional right superior parietal lobule to form an unified body image leading to changes in skin conductance readings. When this dysfunction is acquired, as in somatoparaphrenia,the brain seems sometimes to rationalize the discrepancy by denying ownership of the limb. When the dysfunction is congenital it leads to a feeling that affected area should not be there to begin with and a desire for an amputation.

See also

• Disability pretenders, those who behave as if they are disabled
• Attraction to disability
• Acrotomophilia
• Transvestitism
• Prefrontal Cortex
• Somatoparaphrenia

References

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• Neurological disorders
• Paraphilias