Apotemnophilie : une mise en forme contemporaine de la souffrance psychique ?

Résumé

Le terme d’apotemnophilie a connu un destin particulier. Initialement, il désignait un trouble de l’ordre d’une paraphilie, supposant soit une excitation sexuelle liée au fait d’être amputé avec désir de passer à l’acte, soit la recherche de partenaires amputé(e)s. Ces dernières années est apparu un nouveau concept, celui de Trouble identitaire de l’intégrité corporelle (TIIC) qui fait de ce trouble un trouble de l’identité dont le traitement doit être chirurgical. Dans cet article, nous présentons le cas clinique d’une jeune femme demandant l’amputation d’une jambe suite à des lésions auto-infligées. Nous dressons ensuite un historique de l’évolution de ces concepts, basé sur une revue de la littérature et tentons d’en cerner la dynamique d’apparition, et de questionner la pertinence de ce qu’on peut sans doute considérer comme un syndrome lié à la culture.

Summary

The word « apotemnophilia » was created in 1977. It was first used to describe an extreme paraphilia concerning both the search for amputees as sexual partners, and the fantasies and wishes to be amputated linked to a sexual arousal.

Clinical findings

More recently, the number of self-demand amputations appears to have raised. Some amputations of healthy legs have even been performed in hospital settings, raising important ethical issues. A new category of trouble has been described : the Body Integrity Identity Disorder (BIID). Criterias for its diagnosis have been developed and submitted to DSM V task force. According to clinicians who support the existence of BIID, this disorder is not a paraphilia, don’t overlap with other psychiatric disorders and could be in some ways compared to transexualism. The patient's health would therefore require the amputation of healthy limbs in order to « achieve » themselves and to help them to become « able-bodied » according to their « true self ». Still according to those clinicians, psychiatric symptoms would be either a consequence of the shame resulting from this condition, or a consequence of the doctor's refusal to perform these amputations. An ever growing « grey » litterature on the web support this opinion, but the scientific litterature is still very scarce.

Literature findings

In this paper, we analyse available scientific datas. This review does not support the existence of BIID as a discrete nor a specific condition.

Case-report

In a second part of this paper, we describe the case of a young woman who started asking for above-the-knee leg amputation after a minor knee trauma, while complaining for pain and leg rigidity. Her medical state worsened, probably because of repeated self-inflicted lesions and food restriction, leading to a severe undernutrition and life-threatening hypokaliemia. After some time, her medical state required amputation. This surgery did not resolve her psychological suffering. She never talked about amputation as a way to achieve herself. She did not meet the criterias for BIID. We consider her trouble as an association of a factitious disorder with a borderline personality disorder.

Discussion

In the last part of this paper, we discuss the « grey » scientific litterature about apotemnophilia and BIID. We support the idea that BIID can be considered as a culture-bound syndrome, a contemporary frame for psychological suffering. We think that BIID does not have neither intrinsic nor unequivocal psychopathological meaning. It is a « new way to be mad » (Elliott), a common pathway for the expression of very different kinds of psychological suffering.

Conclusion

Apotemnophilia and BIID are raising important ethical and practical issues for psychiatrists : their opinion will probably be requested by patients and surgical teams having to deal with patient asking for healthy limbs amputation.