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Home / Features / BIID / BIID Basics

BIID Basics

Written by Sean on Wednesday, April 26, 2006

What is in a name?

This disorder has had several different names in the past. It was originally described as Apotemnophilia in 1977. For a short time, it was termed Amputee Identity Disorder (AID) and Furth and Smith wrote the only book that exists on the subject to date: Amputee Identity Disorder Information, Questions, Answers and Recommendations About Self Demand Amputation The most appropriate name, as determined by psychiatrists working in the field, is Body Integrity Identity Disorder, or BIID.

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What is BIID?

Body Integrity Identity Disorder, or BIID, is a psychological condition in which the individual requests an elective amputation. Individuals with this condition experience the persistent desire to have their body physically match the idealized image they have of themselves. This desire forces individuals to deal with the paradox of losing one or more major limbs (i.e. arm[s] or leg[s]) to become whole. In their minds, �??Less is more�?�.

These individuals are not psychotic. In fact, a diagnosis of psychosis excludes a diagnosis of BIID. BIID has been most commonly compared to Gender Identity Disorder (GID). One common factor is that in both conditions, the individuals relate that their feelings and urges have been present since their pre-adolescent years. The trigger appears to be the sight of an amputee. Many individuals can clearly recall the first amputee they saw resulting in a �??recognition�?� response of their hitherto vague feelings of discomfort. This may be as early in life as age 4 or 5.

Currently, the psychiatric and psychologic communities are working to more clearly define the condition and treatment options. Research in this area is very minimal. As a result, every answer leads to more questions.

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How many sufferers are there?

Based on the limited information known, males are much more often affected than females, but the ratio is not defined. Due to the nature of the disorder, accurate numbers for the occurrence in the general population are undetermined. A recent Internet survey attracted over 200 responses, although, whether all the responses were of genuine BIID sufferers is debatable. It would be impossible to determine the number of sufferers as most are too ashamed to admit to their problem. Hopefully, with increasing knowledge about, and acceptance of the condition, more accurate statistics will become available.

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What is the cause?

The cause has not been clearly delineated however several theories have been proposed:

The sight of an amputee in infancy imprints the child�??s psyche and the child feels that that should be their body image.

The child feels unloved and by becoming an amputee may attract sympathy and love. There are strong positive thoughts about becoming an amputee.

The desire is an external manifestation of an unresolved internal conflict.

The condition is a neuro-psychological condition in which there is a structural or functional anomaly of the cerebral cortex (higher part of the brain) related to the limb(s).

Clearly studies of large numbers of patients will be required to make any progress in this field.

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What are the symptoms?

Most BIID sufferers have all or a combination of the following symptoms:

1. A feeling of �??incompleteness and disability�?� as a four limbed individual but a certainty of a feeling of �??completeness and enablement�?� after amputation.
2. A fixed idea about the limb and the level of amputation required. This is most commonly a unilateral above knee amputation but does sometimes manifest as a desire for arm amputation or even amputation of more than one limb.
3. A feeling of intense jealousy at the sight of an amputee.
4. Feelings of shame and unworthiness about the feelings. These individuals feel completely alone and do not believe anyone else can suffer from such bizarre ideas. They may have been in psychiatric treatment without ever informing the therapists of their underlying desire.
5. Repeated episodes of depression and sometimes suicidal thoughts. Sometimes there have been plans of self injury to achieve amputation such as by using shot guns, burning or deliberately infecting wounds.
6. An apparent failure of the currently available psychiatric treatments to resolve their problem.
7. Rehearsal activity (pretending) during which they imitate the amputated state in private and in public.
8. A feeling that they are alone in the world with the desire to become an amputee.

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Is there a sexual component to BIID?

When the condition was initially described by Money he regarded it as a paraphilia (a condition occurring in men and women dependent on a personally or socially unacceptable stimulus or fantasy for optimal initiation and maintenance of erotosexual arousal and the facilitation or attainment of orgasm) and named it �??Apotemnophilia�?�.

Apotemnophilia appears to be a separate condition to BIID as it is defined as a condition characterized by sexual arousal and facilitation or attainment of orgasm dependent upon being oneself an amputee. These individuals are sometimes described as �??Wannabes�?�. The BIID sufferers are a distinct group in that their desire to be an amputee is related to activities of daily living and not purely related to sexual arousal.

Another associated condition called �??Acrotomophilia�?� is defined as a condition characterized by sexual arousal and facilitation or attainment of orgasm being dependent upon a partner who is an amputee. These individuals are known as �??Devotees�?�.

Judging by the membership of the Internet discussion groups it seems that the largest group are the Acrotomophiles and the smallest group the true BIID sufferers. However some BIID sufferers do also have some acrotomophile and apotemnophile behaviour.

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What other conditions may be confused with BIID?

There are several conditions which may cause patients to seek amputation. These include:

• Transsexuals who usually mutilate only the genitals in order to assume the physical appearance of the opposite sex.
• Schizophrenics who may self mutilate in response to voices ordering them to do so or in response to a delusional belief that the body part is defective or bad.
• Patients with a personality disorder, who appear to mutilate to relieve tension or gain secondary advancement.
• Confused patients who may injure themselves due to disinhibition, poor judgement or perceptual difficulties.
• Depressed patients who may mutilate themselves in a failed suicide attempt, or as atonement for perceived sins.
• Patients with Body Dysmorphic Disorder who seek body modification in response to some perceived physical imperfection.
• Patients with Factitious Disorder are so eager to enter the sick person’s role that they will intentionally produce psychological or physical symptoms.

BIID patients appear to seek amputation in order to achieve their perceived body image.

These conditions are further defined on this page.

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How does the condition affect the sufferers?

The condition starts early in life (sometimes as early as 4 or 5) and is always established by puberty. This contrasts with the BDD patients in whom the condition usually starts after puberty. They will often �??pretend�?� when they are alone by binding up their limb(s) to imitate the amputated state. Sometimes, they may design and fabricate prostheses to allow themselves to appear to have the amputation(s) they desire. Some will even pretend in public.

For some, the desire may be associated with sexual fantasy, but for others there is no sexual component. All the true BIID sufferers, in contrast to the apotemnophiles, desire to be amputees in all activities of daily living. In early life sexual activity and pretending may help to alleviate the desire. However as the BIID sufferer ages any sexual component of their condition tends to wane and the non-sexual component becomes more pressing.

Sufferers are often afraid to tell anyone about these feelings because of the perceived reaction they will encounter by telling others about their desire. They often feel that they are the only one in the world who would have such a desire and very few will ever �??come out�?� to their friends or relatives. Many have sought psychiatric or psychological help but often the true nature of their affliction is never revealed to their counselors. Few counselors have ever heard of the condition and none have any experience in attempting to treat any significant number of cases. Most sufferers gain little help from psychiatric or psychological therapy and any treatment merely helps to control the desire rather than to abolish it.

In some cases, the desire becomes strong enough that the person attempts to injure themselves in order to achieve amputation. Methods include freezing with dry ice, lying on railway tracks, using firearms, mechanical equipment etc. Some of these are disguised as accidents or failed suicide bids. Any act of this magnitude is, by default, life threatening.  No one knows how many such accidents that resulted in limb-loss were actually the result of a person with BIID trying to effectively become an amputee.

Some sufferers have achieved amputation by formal elective surgery either by feigning limb threatening illness or by finding a sympathetic surgical service.

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Why are surgeons so unwilling to carry out amputations on BIID sufferers?

The basic ethos that governs medical practice is that the doctor should do no harm to his patient. The amputation of a limb is regarded by most surgeons as a major mutilating action resulting in disability. Most patients who have amputations for pathology are devastated by the event and this is the image in the mind of the amputation surgeon. Few surgeons can conceive that amputation of a normal limb can be a benefit to the patient and few psychiatrists or psychologists would ever consider referring patients for surgical treatment.

Surgeons do not operate in isolation and tend to have large teams of doctors, nurses and paramedical staff involved in the care of the patient.  Any of those involved can object to the care offered to the patient and in these days of intensive scrutiny the surgeon may be subjected to investigation and possible suspension.

The attitudes of the general public also have a part to play. The two elective amputations carried out by Smith in the UK in 1997 and 1999 resulted in no adverse publicity at the time as the reasons were accepted by the relatively enlightened hospital staff. However the story of the cases was leaked to the press in 2000 and this resulted in widespread publicity some highly critical but some supportive. The procedure was effectively banned in the National Health Service. Attempts to carry out further operations in a private hospital were stopped by the hospital�??s fear of further publicity. Hence the current situation in which no hospital is prepared to allow the operations to proceed.

Some private hospitals outside of Europe and the US may be prepared to carry out amputations but the quality of surgical practice is difficult to guarantee.

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