Theorized Causation for Body Integrity Identity Disorder
Often, individuals with Body Integrity Identity Disorder (BIID) feel incomplete with having one or more limbs and this feeling of incompleteness, as well as motivation for limb amputation, stem from a variety of reasons. Which raise the question: Is BIID a psychological and or a biological condition? What is known about this disorder is the distinct association with distress and impairment, extreme enough to the point of two thirds of those with BIID attempt self-amputation at the risk of death (First, 2005). To better understand treatment of BIID, one needs to explore the possible psychological and biological components that cause this disorder.
First, to better understand this disorder one should look at childhood predictors. The majority of BIID suffers report witnessing an individual with an amputation early in life (First, 2005). In contrast to other children, those with BIID report a fascination with physically handicapped individuals (First, 2005). This fascination mirrors characteristics of Body Dysmorphic Disorder, in which individuals are aware of their desire’s abnormality and feel torn between the pros and cons of changing their body (de Vignemont, 2010). Also, in a study conducted by the University of Amsterdam and The Netherlands Institute of Neuroscience at the Royal Academy, researchers found that the onset of BIID occurs in early childhood at an average age of 6.7 years and most commonly among males, who comprised eighty percent of the particapents (Blom, Denys, & Hennekan, 2012). Blom et al. (2012) states that “the male predominance can be reflective of the fact that men suffering from this disorder are overrepresented in reported cases compared to women because of the violent behavior involved in the act of self-amputation.” (Blom, et al., 2012)
Further, the early onset of the mismatch between actual and perceived body schema suggests that BIID is a psychosis, additionally suggesting that individuals inherit the disorder. However, Khalil and Richa (2012) found in their case review, that patients “desire for limb amputation is not motivated by delusion, nor as a defense mechanism for attention” (p. 4). This finding supports First’s (2005) suggestion that one can rule out delusion as cause a of BIID because those with the disorder recognize that the unwanted limb is in fact their own and fully functional. The early onset of a desire to self-amputate appears to depend on various factors such as stressful life events, personality traits, and pretending play (i.e., imaginative and fantasy role play). Shortly after the development of BIID, sufferers report medical problems concerning the undesired body part, and these medical problems often manifest due to avoidance of use (Blom et al., 2012). Moreover, Blom’s (2012) findings complement First’s (2005) research, which emphasizes sufferers’ preoccupation with amputation that first manifests itself by their pretending to be an amputee. One can hypothesize that pretend play fuels the development of BIID on a biological basis because it contributes to the neurological remapping that occurs among adolescents, as the brain pruning process still takes place.
Additionally, Kasten (2009) proposes a sexual motive for amputation. One third of surveyed BIID sufferers state that sexual arousal was a leading cause for amputation. Among those who expressed sexual motivation for amputation, the amputation site would often change (Kasten, 2009). Suggesting that these individuals also suffer from paraphilia, a disorder in which self-elected amputation becomes a typical route to sexual arousal. This sexual component, in which individuals fixate on amputation to alleviate sexual anxiety suggests that those with BIID suffer from a psychosexual motive. However, in a study conducted by Blom, Hennekam, & Denys (2012), the participants report that sexual arousal is not a primary or secondary motivation for amputation. Instead, the primary motivation reported was to feel satisfied and whole (Blom et al., 2012). Although the sexual perspective supports a psychological cause, the study conducted by Blom et al. (2012) found that all but one subject reported a non-psychotic diagnosis and did not score positive on the Mini-International Neuropsychiatric Interview for psychotic symptoms.
Psychiatric co-morbidity in BIID sufferers, and literature reviews, suggest no distinction between BIID sufferers and the general public in terms of psychological processing, except for increased depressive symptoms and mood disorders, which are secondary, and do not represent a separate manifestation. McGeoch, Brang, Huang, Lee, Ramachandran, & Song (2011) propose the reversal of phantom limb syndrome, in which the brain fails to map a particular body part. Specifically, McGeoch et al. (2011) provided direct evidence that the sense of incompleteness corresponds to a dysfunction in activity in the right parietal lobe, where the brain mass is thinner in those with BIID. Their findings support the theory that BIID is not simply a paraphilia, but rather a neurological syndrome. Thus, the brain’s disconnect leads the sufferer to rejected acknowledgment of the disputed body part, which in turn leads to a life of anxiety, depression, and internal-conflict. These symptoms may lead individuals to self-amputate, even with the awareness that the procedure is life threatening. Although McGeoch et al.’s (2011) study investigates the tactile perception (i.e., awareness of touch), which is usually associated with body schema rather than body image, it does not explain the body/mind spatial relationship, where the mind is continuously updating limb awareness during movement (de Vignemont, 2010). Although, this neurological theory is compelling as evidence as to the causation of BIID, much more research needs to be conducted before a clear causation of BIID can be made.
Blom, R. M., Denys, D., Hennekam, R. C., (2012). Body integrity identity disorder. PloS One, 7(4): e34702. doi:10.1371/journal.pone.00034702.
Brang, D., McGeoch, P. D., Ramachandran, V. S. (2008). Apotemnophilia: A neurological disorder. NeuroRport, 13(19), 1305-1306.
de Vignemont, F. (2010). Body schema and body image – pros and cons. Neuropsychologia, 48(3), 669-680. doi:10.1016/j.neuropsychologia.2009.09.022.
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.
Kasten, E. (2009). Body integrity identity disorder (BIID): Interrogation of patients and theories for explanation. Fortshritte de Neurologie – Pyschiatrie, 77(1), 16-24.
Khalil, B. R., Richa, S. (2012). Apotemnophilia or body integrity identity disorder: A case report review. The International Journal of Lower Extremity Wounds, 1-7.
McGeoch, P. D., Brang, D., Huang, M., Lee, R. R., Ramachandran, V. S., Song, T. (2011). Xenomelia: a new right parietal lobe syndrome. Journal of Neurology, Neurological. doi:10.1136/jnnp-2011-300224.