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Apotemnophilia is a disorder characterized by the intense and long-standing desire for amputation of a specific limb. Another term for the condition is body integrity identity disorder (BIID), but this has come to apply to not only those who desire an amputation but also those who want a range of disabilities including deafness, blindness and a spinal cord injury.

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Apotemnophilia (xenomelia) has features in common with somatoparaphrenia. Some apotemnophiles seek surgeons to perform an amputation or purposefully injure a limb in order to force emergency medical amputation. A separate definition of apotemnophilia is erotic interest in being or looking like an amputee.

Apotemnophilia (xenomelia) was first described in a 1977 article by psychologists Gregg Furth and John Money: "Apotemnophilia: two cases of self-demand amputation as paraphilia." Until recently, the primary explanation for Apotemnophilia was psychological/psychiatric.

Neurological Etiology

In 2008, V.S. Ramachandran, David Brang and Paul D. McGeoch conducted research that suggested Apotmenophilia/Xenomilia is a neurological disorder caused by an incomplete body image map in the right parietal lobe. The study carried out by David Brang, Paul McGeoch and V.S. Ramachandran in 2008 was on two subjects. In 2011 Paul McGeoch et al. published the results of an experiment in which they were able to obtain MEG images of the parietal lobes for four research subjects, all of whom desired amputation.

In 2011 a group of researchers at the University of Southern California (Brain and Creativity Institute) proposed an alternative neurological hypothesis. These researchers proposed that "individuals with BIID may have a discrepancy between the commands from the motor cortex to the parietal lobe and from the sensory feedback to the same regions in the parietal lobe". This theory was based on the discovery that individuals who desire amputation sometimes experience phantom limbs after amputation.

In 2013, Hilti et al., described structural abnormalities in the superior parietal lobule as well as the right anterior insula of 13 men with xenomelia, supporting parallels between xenomelia and disturbed self-consciousness in disorders like somatoparaphrenia.

A number of clinical observations, such as the switching of a longstanding desire from a left-sided to a right-sided leg amputation or the sudden occurrence of new amputation desires after previous ones were satisfied are not easily explainable by the sole reference to neural mechanisms.

Classifications: Body Integrity Identity Disorder (BIID)

The term body integrity identity disorder was coined in 2005. In a study conducted by Michael First, 52 individuals were administered a structured telephone interview, which helped characterize the altered bodily self-consciousness that culminates in desire for amputation. The use of the term "Body Integrity Identity Disorder" suggests that Apotemnophilia is an identity disorder as defined in the DSM-IV.

Patients diagnosed with apotemnophilia are sometimes classified as being patients who experience body integrity identity disorder (BIID). In a 2014 review of the psychiatric and neurological literature, Anna Sedda and Gabriella Bottini stated that there is no consensus as to the best way to classify the desire for amputation:

"In summary, psychological/psychiatric explanations for the desire to amputate a healthy limb include two main hypotheses: a sexual compulsion, belonging to the paraphilic core, and an identity disturbance, paralleling gender identity disorder. At present, no new psychological/psychiatric explanations have been proposed; neither has this condition been included in the DSM-5 classifications."

Symptoms and Treatment

Apotemnophia / Body Integrity Disorder (BIID) is a is a rare, infrequently studied and highly secretive condition in which there is a mismatch between the mental body image and the physical body. Apotemnomphilia is characterized by an intense desire for amputation of a limb. Currently BIID is not included in the International Statistical Classification of Diseases 11 or the Diagnostic and Statistical Manual of Mental Disorders IV. It is often not known to surgeons, neurologists and psychiatrists. BIID individuals typically avoid healthcare and often act out their desires by pretending they are disabled or perform actual self-amputation.

A 2012 study concluded, based on interviews with 54 individuals, that the main rationale for their desire for body modification (amputation) was to feel complete or to feel satisfied inside. Based on the results of the survey, researchers concluded that psychotherapy was often supportive, but did not help diminishing BIID symptoms. Individuals reported that antidepressants were helpful in reducing depressive symptoms related to BIID, but that antipsychotics were not. Actual amputation of the limb was effective in all 7 cases who had surgical treatment.

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 allowing his or her patients to remain unhappy. 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, in-depth 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 dysphoria.

A 2014 review concluded that

"In conclusion, the 37 years of study of this desire to be disabled...appears challenging to understand, even using state-of-the-art technologies. Much more effort is needed to find a solution and, finally, a treatment for the distress these individuals experience. This still-obscure condition needs a multidisciplinary approach to go beyond the “simple” clinical/experimental frame, and requires a much more complex model that also includes social and ethical aspects."

See also

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

References

1. Sedda, A; Bottini, G (2014). "Apotemnophilia, body integrity identity disorder or xenomelia? Psychiatric and neurologic etiologies face each other". Neuropsychiatric disease and treatment. 10: 1255–65. doi:10.2147/NDT.S53385. PMC 4094630. PMID 25045269.{{cite journal}}: CS1 maint: unflagged free DOI (link)
2. Kasten E.,Stirn A. (2009). Body integrity identity disorder (BIID). Z. Psychiatr. Psychol. Psychother. 57,
3. Sorene E.D.,Heras-Palou C., Burke F.D.,(2006). Self-amputation of a healthy hand: a case of body integrity identity disorder. J. Hand Surg. Br. 31B, 593–595
4. Peter Brugger,Bigna Lenggenhager,Melita J. Giummarra,Xenomelia: A Social Neuroscience View of Altered Bodily Self-Consciousness,Front Psychol. 2013; 4: 204. Published online 2013 Apr 24. Prepublished online 2013
5. Baril, A. and K. Trevenen (2014). "Exploring Ableism and Cisnormativity in the Conceptualization of Identity and Sexuality 'Disorders'", Annual Review of Critical Psychology, 11, p. 389-416 Read online.
6. Sedda,Anna,Bottini,Gabriella,Apotemnophilia, body integrity identity disorder or xenomelia? Psychiatric and neurologic etiologies face each other,Neuropsychiatric Disease and Treatment, 2014,10:,1255–1265
7. Rianne Blom,Raoul Hennekam, Damiaan Denys,Body Integrity Identity Disorder,PLoS One. 2012; 7(4): e34702.Published online 2012 Apr 13.
8. Rianne Blom,Raoul Hennekam, Damiaan Denys,Body Integrity Identity Disorder,PLoS One. 2012; 7(4): e34702.Published online 2012 Apr 13.
9. Mo Costandi,The science and ethics of voluntary amputation,The Guardian,Wed 30 May ‘12
10. A.Dua,Apotemnophilia: ethical considerations of amputating a healthy limb,J Med Ethics 2010;36:75e78. doi:10.1136/jme.2009.031070 77
11. First, M. B. (2005). "Desire for amputation of a limb: Paraphilia, psychosis, or a new type of identity disorder". Psychological Medicine. 35 (6): 919–928. doi:10.1017/S0033291704003320. PMID 15997612.
12. Lawrence, A. A. (2006). "Clinical and theoretical parallels between desire for limb amputation and gender identity disorder". Archives of Sexual Behavior. 35 (3): 263–278. doi:10.1007/s10508-006-9026-6. PMID 16799838.
13. Lawrence, A. A. (2009). "Erotic target location errors: An underappreciated paraphilic dimension". Journal of Sex Research. 46 (2–3): 194–215. doi:10.1080/00224490902747727. PMID 19308843.
14. Sedda,Anna,Bottini,Gabriella,Apotemnophilia, body integrity identity disorder or xenomelia? Psychiatric and neurologic etiologies face each other,Neuropsychiatric Disease and Treatment, 2014,10:,1255–1265

External links

• The dictionary definition of apotemnophilia at Wiktionary

• Neurological disorders
• Paraphilias
• Amputations
• Identity disorders