Apotemnophilia Masquerading as Medical Morbidity

J. Mike Bensler, MD, Douglas S. Paauw, MD, FACP

Disclosures

South Med J. 2003;96(7) 

In This Article

Discussion

We think that this report is the first case of a patient with apotemnophilia who presented in his 20s. His psychiatric illness led him to incur significant inpatient medical and surgical hospital costs on several occasions in multiple hospital settings. This hospitalization was the first to bring attention to his true disorder, because none of his previous medical encounters had raised any questions or suspicion of apotemnophilia as a possible cause of his repeated medical consultations.

Consistent with previously mentioned case reports,[1,2,3,5] our patient was secretive about his attempt to self-amputate his legs. Although his nerve conduction studies were found to be characteristic of early GBS,[6] his lack of reliable physical examination findings, combined with his purposeful omission of a history of self-induced lower-extremity ischemia with a tourniquet, made the diagnosis of apotemnophilia elusive at his initial encounter. Instead, he was given an alternative diagnosis requiring expensive outpatient pharmacologic therapy that did not help the patient and needlessly increased the already burgeoning costs of his health care. His covert desire for self-amputation also complicated his admission to the hospital from the emergency department: He was improperly admitted to the inpatient neurology ward and not to the general surgery ward, because it was thought that his cellulitis might be a rare complication of GBS. Previous case reports have illustrated that patients with apotemnophilia recognize that others do not validate their desire for self-amputation;[1] thus, maintaining secrecy about the origin of the injured limb may be the only means by which these patients can undergo the sought-after amputation.[1,5] Valuable hospital resources were used unnecessarily before the patient's history of attempted self-amputation was obtained.

At the end of our patient's hospitalization in the psychiatric ward and after his lengthy stay in the neurological, surgical, and medicine inpatient wards, the patient revealed his wish to have bilateral BKAs. His reluctance to undergo bilateral incisions and drainage instead of the desired BKAs for cellulitis was the first significant clue leading to the diagnosis of apotemnophilia. The patient's medical history of repeated lower-extremity morbidity and his family history of psychiatric disease also were characteristic of patients with apotemnophilia,[1] and the symmetric, distal phalangectomies of his feet were indicative of psychiatric illness presenting as medical morbidity. Patients with apotemnophilia fantasize about accomplishing great feats despite having a handicapping amputation,[1] and the patient's claim of being a world-class artist may have stemmed from such a preconceived fantasy. He could have continued painting if his attempt to undergo BKAs had been successful. Therefore, his motivation to undergo lower-extremity rather than upper-extremity bilateral amputations was most likely due to his fantasy of remaining a superior artist and excelling in painting despite of having no feet or legs.

Money et al's[1] original case reports of two individuals with apotemnophilia describe individuals who were much older than our patient, and subsequent case reports have described individuals in their late 40s[3] and 60s.[2] The accessibility and availability of information about apotemnophilia on the Internet may be a factor in the relatively early age of presentation of this patient compared with patients discussed in previous case reports. Money et al[1] remarked that apotemnophilia was first brought to public attention in the September and October issues of Penthouse magazine in 1972. Fewer than a dozen case reports of apotemnophilia currently exist in the literature. The scant literature available on apotemnophilia is currently too small to draw conclusions about the true prevalence of this rare disorder.

There are reportedly several Internet sites that provide access to amputee pornography and information about so-called amputee devotees, or acrotomophiles[7] (ie, amputee partners), and "wannabes," or people with apotemnophilia, as well as listservs and other web-based discussion sites dedicated to apotemnophilia. Although our patient did not specifically mention any web-based resources, he reported frequent nonspecific use of the Internet. The patient's wife also confessed that her husband subscribed to various magazines about lower-extremity prosthetics, although he denied having any subscriptions to medical journals or magazines related to amputation.

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