Onset during early childhood, the struggle that patients with Body Integrity Disorder (BIID) suffer from can be explained by overwhelming symptoms, including but not limited to feelings of incompleteness, discomfort, stress, depression, and especially the rejection of certain body parts. Body Identity Integrity Disorder is a rare condition wherein an individual has strong desires to amputate or paralyze specific part(s) of their body because of an incongruity or disunity between mental image and the biological body.
According to recent studies, BIID may be considered as a neurological rather than a psychological disorder. According to earlier studies by Ramachandran & McGeoch, it is more commonly acknowledged that BIID is a result of a dysfunction in the right superior parietal lobule after performing various skin conductance experiments. BIID occurs because the affected body part is not included in what is represented as the body image. The right superior parietal lobe is responsible for the perception of the body and the integration of somatosensory information, which allows individuals to have multiple neural representations of the body. Those representations partially contribute to what is known as body image, a term that broadly describes how an individual perceives, feels, and thinks about themselves.
One study by Riane M. Blom and others applied voxel based morphometry (VBM), a method that investigates differences in brain anatomy by detecting changes in gray matter, and found that there are volumetric differences in the left premotor cortex (responsible for planning and programming voluntary movements) and the cerebellum (responsible for balance, posture, and coordination). Both the left premotor cortex and the cerebellum are necessary for feelings of body-ownership and integration of multisensory information. In BIID patients, the differences in gray matter volume and a dysfunction in how multisensory information is integrated may result in the incongruity that patients experience between their mental image and their physical body.
Despite all of the research that has been conducted within the past two decades on the topic of BIID, knowledge on BIID is limited in the medical community and not many medical professionals are accepting of the idea of amputating or paralyzing able-bodied people. Due to the stigma of mental disorders, and the lack of any successful psychotherapeutic or pharmaceutical treatments for BIID patients, many patients either perform self-amputation, or pretend to be physically disabled rather than seeking to be amputated by a medical professional. Among the 300 documented cases of BIID worldwide, one individual of the few hundred attempted to remove their source of discomfort and distress.
Nick O’Halloran recalls having his first desire to amputate his right leg when he was only ten years old. He explains that three inches below the right hip, his right leg does not feel like it belongs to him. He explained in an interview that he made attempts to damage his right leg by injecting medical grade alcohol into the limb so that physicians would be forced to amputate it. Although amputation was Nick O’Halloran’s end goal, he unfortunately got scammed to pay $26,956 for an amputation that never occurred by a scammer who claimed they could introduce him to a physician. The cumulation of painful events from his BIID drove him to the brink of suicide. As there are no physicians who are willing to amputate his right leg, he pretends that he does not have one which reportedly makes him feel better and more “complete.”
Cases such as Nick O’Halloran’s are indicative of the ethical issue that is often brought up with BIID: should patients be given the autonomy to remove healthy body parts? Although cases of BIID are rare, and surgeons may feel reluctant or opposed to perform a procedure that would give a physical disability to a healthy individual, there are arguments that support patient autonomy for individuals suffering from BIID. Nick O’Halloran is not the only person who has gone to extreme measures to paralyze and amputate his leg. In fact, there have been many cases of people who would submerge their limb in dry ice or shoot their limb off, in hopes of forcing physicians to amputate the body part. However, incidents such as these cause considerably more harm to the individual since there are risks of health complications and death.
Sabine Müller, a pediatric neuro-oncologist, says otherwise in her research paper which questions the ethical justifications of amputating healthy limbs in BIID patients. According to Müller and others, recent neurological results suggest that BIID is a brain disorder that affects an individual’s body image of themselves. Thus, if BIID is considered to be a neuropsychological disturbance, which includes impairments to an individual’s insight into their illness and a lack of autonomy, then using amputation as a method of treatment should be contraindicated. Other methods including rTMS (repetitive magnetic stimulation), movement therapy, and ear-canal rinsing methods are suggested as less-intrusive solutions. Furthermore, amputation as a treatment for BIID individuals are reported to have only a 70% success rate in resolving symptoms.
Robert Smith, a surgeon at the Falkirk and District Royal Infirmary, reportedly performed two voluntary amputations in 2002: one for a patient from England, and another for a patient from Germany. Both patients were suffering from what is now known as BIID, but the surgeon and the hospital both received backlash as the amputation of healthy body parts were deemed as inappropriate. Since then, British hospitals have not offered voluntary amputation procedures.
In a recent study, the idea of using augmented reality (AR) as a therapeutic adjunct to treatment for individuals suffering from BIID was introduced as a plausible solution because there is currently no ethically unambiguous, or successful method to relieve or reduce symptoms of BIID. In this study, two BIID patients went through multiple trials of “AR-based simulation” which virtually amputated their affected limb. Both patients reported that after multiple trials of AR-based simulation exposure, they felt a reduction in their BIID symptoms, and stated that it was an emotional experience to feel “complete.” Although there are limitations to consider in the study such as the validation of the research’s verbal Likert scale (VLS), or the wider application of AR simulation on more severe cases of BIID, alternatives that provide ethically unambiguous benefits to both the patient and the medical profession are a step forward to what the future may bring.
References:
Blom, R. M., Hennekam, R. C., & Denys, D. (2012). Body integrity identity disorder. PloS one, 7(4), e34702. https://doi.org/10.1371/journal.pone.0034702
Blom, R. M., van Wingen, G. A., van der Wal, S. J., Luigjes, J., van Dijk, M. T., Scholte, H. S., & Denys, D. (2016). The Desire for Amputation or Paralyzation: Evidence for Structural Brain Anomalies in Body Integrity Identity Disorder (BIID). PloS one, 11(11), e0165789. https://doi.org/10.1371/journal.pone.0165789
Costandi, M. (2012, May 30). The science and ethics of voluntary amputation | Mo Costandi. The Guardian. https://www.theguardian.com/science/neurophilosophy/2012/may/30/1
Dunn, J. (2017, March 31). Healthy man is so desperate to have his fully working leg AMPUTATED he injects it with alcohol and has paid £20,000 for a fake operation. Daily Mail. https://www.dailymail.co.uk/news/article-4367098/Man-desperate-healthy-leg-AMPUTATED.html
Dyer C. (2000). Surgeon amputated healthy legs. BMJ (Clinical research ed.), 320(7231), 332.
Müller S. (2009). Body integrity identity disorder (BIID)--is the amputation of healthy limbs ethically justified?. The American journal of bioethics : AJOB, 9(1), 36–43. https://doi.org/10.1080/15265160802588194
Sedda A. (2011). Body integrity identity disorder: from a psychological to a neurological syndrome. Neuropsychology review, 21(4), 334–336. https://doi.org/10.1007/s11065-011-9186-6
Turbyne, C., Koning, P., Zantvoord, J., & Denys, D. (2021). Body integrity identity disorder using augmented reality: a symptom reduction study. BMJ case reports, 14(1), e238554. https://doi.org/10.1136/bcr-2020-238554