Amputating a Healthy Limb and BIID

A look at body integrity identity disorder (BIID)

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According to Sophocles, Oedipus the King killed his father and had sex with his mother. It wasn't until years later, however, that Oedipus found out that he committed patricide and incest—initially not knowing that his father was his father and his mother was his mother. After Oedipus found out what he did, he struck out his own eyes. Oedipus's reason for self-blinding involved guilt and was allegorical: He was initially blind to the atrocious acts that he committed.

 

The ancient Greeks probably couldn't fathom somebody blinding himself without some tragic reason on the scale of Oedipus's crimes. However, in modern society, a few people exhibit "ownership" issues with specific body parts and obsessively wish for disability. These people have a condition called body integrity identity disorder (BIID) and often after years of suffering request to have surgery that results in amputation, blindness, deafness or paraplegia. 

As you can probably imagine, few surgeons are keen on interfering with organs or limbs without disease. However, BIID is a complex problem, and some experts advocate for radical surgery as effective treatment.

BIID Examined

In the late 1700s, a French surgeon was forced at gunpoint to amputate a man's healthy limb. After the surgery, the man sent the surgeon payment and a letter of gratitude claiming that the surgery made him feel better.

In 2000, the public found out that a Scottish surgeon named Robert Smith had performed leg amputations on two patients with seemingly normal limbs. When the CEO of Smith's hospital figured out what Smith had done, Smith was forbidden to perform any more amputations. However, in the wake of these amputations, the debate concerning healthy amputation and other seemingly "unnecessary" and debilitating surgery gathered steam.

In 2015, a 30-year-old woman named Jewel Shuping claimed that she had her psychologist pour drain cleaner into her eyes so that she could realize her lifelong desire of being blind. To be fair, the veracity of Shuping's claims is disputed; nevertheless, accounts of this assisted blinding once again highlight BIID.

People with BIID complain of feeling "overcomplete" and alienated from a body part be it an eye, limb or so forth. More specifically, these feelings are lifelong obsessions that result in considerable psychic suffering and trauma.

It's unclear what causes BIID. In some people, issues with body identity or ownership can be traced back to definitive pathology such as a brain tumor. However, in most people with BIID, the etiology or cause of the disease remains to be elucidated.

Researchers who study BIID have observed brain changes in individuals with the disease. Specifically, the parietal cortex, premotor cortex, and insula seem to be involved. However, it's unclear whether these brain regions lead to BIID or occur as a consequence of BIID.

Treatment of BIID     

Without a clear understanding of what causes BIID, it's difficult to treat the disease. Antidepressants and psychotherapy do little for the disease. Furthermore, heavier psychotropic medications like antipsychotics haven't been tested in this patient population.

Interestingly, people with BIID who desire leg amputation feel better after the procedure and report improved quality of life. Of note, the two people on whom Robert Smith, the Scottish surgeon, performed surgery, felt remarkably better after surgery and went on to live happily with prostheses.

Many people with BIID practice living with a disability. These people are labeled "pretenders." By pretending to live with a disability, these people experience some short-term relief similar to the temporary relief people with obsessive-compulsive disorder feel after carrying out a compulsion.

Most surgeons who encounter BIID have an alarmed reaction to the prospect of using radical surgery to treat the illness. These surgeons claim that anybody who wants to amputate a "healthy" limb has mental illness and limited insight that compromises her ability to give informed consent.

However, most people with BIID aren't psychotic and don't have delusions. Moreover, the depression that some of these people with BIID experience develops after living with BIID for some time and is likely a consequence not cause of the condition.

In a paper titled "Body Integrity Identity Disorder Beyond Amputation: Consent and Liberty," author Amy White claims that the decision for a person with BIID to undergo elective surgery to remove a body part isn't necessarily coerced, incompetent or uninformed; thus after a comprehensive screening process, patients with BIID could be candidates for radical surgery.

White also likens BIID to gender dysphoria and radical surgery in those with BIID to sexual reassignment surgery. Specifically, both people with gender dysphoria and BIID feel trapped in a body that is somehow wrong and desire surgery to correct the problem.

Conversely, in a paper titled "Body Integrity Disorder--Is the Amputation of Healthy Limbs Justified?," author Sabina Müller posits that the cost of radical surgery for BIID is too high, and people who receive it will no longer be able to work and will require lifetime care and rehabilitation.  

Müller also questions whether people with BIID who request radical surgery lack insight into their illness and suggests alternative therapy:

BIID probably is a neuropsychological disturbance that includes missing insight into the illness and a specific lack of autonomy. Instead of curing the symptom for the price of an irreversible bodily damage, a causal therapy should be developed in order to integrate the alien limb into the body image.

We're probably a long way off from ever figuring out how to exactly help people who experience BIID. First, research into BIID is low power because very few people have the condition. Much of what we know about BIID is based on anecdotal accounts. Second, BIID likely involves complex neurological processes that we have yet to elucidate; after all, the brain is ineffably complicated. Third, radical surgery for BIID is mired in ethical considerations that further obfuscate our understanding and appreciation of treatment.   

Selected Sources

Article titled "Neural Basis of Limb Ownership in Individuals with Body Integrity Identity Disorder" by MT van Dijk published in PLOS ONE in 2013.  

Article tilted "Body Integrity Identity Disorder (BIID)—Is the Amputation of Healthy Limbs Ethically Justified?," by Sabina Müller published in The American Journal of Bioethics in 2009.  

Article titled "Body Integrity Identity Disorder Beyond Amputation: Consent and Liberty" by Amy White in HEC Forum in 2014.  

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