To the Editor:
I would like to make a belated comment on two aspects of the important article by First (Reference First2005) entitled ‘Desire for amputation of a limb: paraphilia, psychosis, or a new type of identity disorder’.
Firstly, I applaud his method of using the internet and telephone interviews to overcome the problems of reporting bias and false inferences that may result from the examination of small numbers of case histories. However, his method could be enhanced if patients were asked to nominate a medical practitioner who could supply some corroborative history. The doctors could be identified through their medical registration details and the patient's anonymity would be preserved.
Secondly, although Professor First's paper and other publications about body identity disorder refer to patients who actually self-amputate their own limbs (Bayne & Levy, Reference Bayne and Levy2005; First, Reference First2005) I could not find a single case of deliberate self-inflicted lower-limb amputation published in the medical literature. Moreover, there are only two cases of self-inflicted upper limb amputation by non-psychotic patients. One was a middle-aged man who had a medical amputation of a lower limb and later self-amputated a hand (Sorene et al. Reference Sorene, Heras-Palou and Burke2006). The second case involved a woman who amputated because she believed her hand had done ‘bad things’ (Brenner, Reference Brenner1999). The other cases of self-amputation cited in the introduction in Professor First's paper were reported to suffer from psychosis (Schlozman, Reference Schlozman1998; Tavcar et al. Reference Tavcar, Dernovsek and Zvan1999).
Therefore, excluding a small number of cases that were anonymously assessed via telephone, only one patient in the medical literature with body identity disorder actually self-amputated a limb. When considering if an elective amputation should be performed to prevent self-amputation in cases of body identity disorder the extreme rarity of this complication should be considered.
Declaration of Interest
None.
The Author replies:
Although most individuals with body integrity identity disorder (BIID) are not at serious risk for self-amputation of a limb, according to the 2005 study, a significant minority are at risk: 12% reported self-amputation of a limb, 10% reported that they had amputated one or more fingers, and 6% reported having made an unsuccessful attempt. In his letter, Dr Large seems to doubt the credibility of these reports based primarily on the paucity of published case reports in the medical literature. While the study's methodology of relying solely on subject self-report inevitably raises questions about the veracity of the reports, given the secretive nature of individuals with this condition, the absence of case reports in the medical literature is not at all surprising.
Individuals with BIID are not psychotic, being fully aware that other people are likely to consider their desires for amputation to be ‘crazy’. Consequently, many individuals who attempt self-amputation try to stage it to look accidental. For example, as reported in the documentary film ‘Whole’, a middle-aged man became a LAK (left above knee) amputee by shooting his left knee at close range with a shotgun, and then claimed it was the result of a hunting accident. Thus, attempts to self-amputate may have appeared to medical personnel to be accidental rather than intentional and hardly worthy as the subject of a case report. Any doubt that some individuals with BIID become desperate enough to resort to self-amputation is dispelled by the case studies included in the various documentaries and television news programmes (e.g. ‘Whole’, ABC News Primetime Live, BBC Horizon) that have examined this intriguing but unfortunate condition.
Declaration of Interest
None.
