A New Way to Be Mad (Caution: the referenced article has graphic details not for the squeamish) Carl Elliott, a philosopher of psychiatry, with a medical degree, writes a long reflection on the growing epidemic of apotemnophilia, a psychological malady in which people seek the amputation of one or more of their limbs without medical cause. This is done with or without the assistance of a surgeon, some of whom feel there are no humane alternatives to relieve their patients’ distress. (“It was the most satisfying operation I have ever
performed. I have no doubt that what I was doing
was the correct thing for those patients”, said one.)

was interested in the way that previously
little-known psychiatric disorders spread, sometimes
even reaching epidemic proportions, for reasons
that nobody seems fully to understand. But I had
never heard of apotemnophilia or acrotomophilia
before the Falkirk story broke. I wondered: Was this
a legitimate psychiatric disorder? Was there any
chance that it might spread? …I also wondered about the ethical and
legal status of surgery as a solution. Should
amputation be treated like cosmetic surgery, or like
invasive psychiatric treatment, or like a risky
research procedure?

Other interesting questions — is this a problem of sexual desire (there are certainly large numbers of “devotees” who are sexually aroused by people missing limbs, but it does not appear that the “wannabes”, those who seek amputation, are sexually motivated) or a disorder of body image or sense of self? What does it say about the nature of our self-identity? What relationship does it bear to other, less extreme, body modification techniques in our own and other cultures? What is the balance between its psychological, possible neurobiological, and sociological determinants? How deep do the homologies between amputation-by-choice and sex-reassignment surgery go? Is it adequately explained as a subset of some other existing category of psychopathology — e.g. body dysmorphic disorder, obsessive compulsive disorder, the paraphilias — or is it something distinct from all of them? More radically, is it a disorder at all? If it is, what is to be considered acceptable treatment, in light of the “extraordinary and often very destructive collaboration” between psychiatry and surgery over the past seventy-five years?

clitoridectomy for
excessive masturbation, cosmetic surgery as a
treatment for an “inferiority complex,” intersex
surgery for infants born with ambiguous genitalia,
and — most notorious — the frontal lobotomy. It is a
collaboration with few unequivocal successes. Yet
surgery continues to avoid the kind of ethical and
regulatory oversight that has become routine for
most areas of medicine.

I’ve long had professional concern about the role that popularizing faddish new diagnoses may have in spreading them. Consider for example multiple personality disorder, which I’m convinced barely exists if at all but has hordes of adherents (“wannabe” sufferers, and “devotee” clinicians). Dr. Elliott has a fine summary of the arguments of a historian of medicine, Ian Hacking, whose thoughtful work about how “transient mental illnesses” arise and take hold I’ve followed closely.

Crucial to the way this worked is what Hacking calls
the “looping effect,” by which he means how a
classification affects the thing being classified.
Unlike objects, people are conscious of the way
they are classified, and they alter their behavior
and self-conceptions in response to their
classification…In the 1970s, he
argues, therapists started asking patients they
thought might be multiples if they had been abused
as children, and patients in therapy began
remembering episodes of abuse (some of which may
not have actually occurred). These memories
reinforced the diagnosis of multiple-personality
disorder, and once they were categorized as
multiples, some patients began behaving as multiples
are expected to behave. Not intentionally, of
course, but the category “multiple-personality
disorder” gave them a new way to be mad.

Is apotemnophilia going to be a particularly malignant example of such contagion? What is the balance between the extent to which cultural and historical conditions reveal, as opposed to create, new disorders? How far do we want to go in regarding it as a psychiatric diagnosis, including it in DSM-V, the next edition of the “Bible” of officially acceptable diagnoses (and, by the way, the basis for insurance reimbursements). In essence, is this going to spread like a new meme, to which Hacking refers as “semantic contagion”? Its severity may be enhanced by the potential for connectivity among “devotees” and wannabes”. As Dr. Elliott points out, part of the motivation of apotemnophiles may be an aspiration to heroism, and of their devotees to hero worship, which the web facilitates tremendously. One discussion group on the topic has over 1400 participants. Atlantic Monthly