Is our society slightly off? Whoever recommended amputation of healthy limbs?

 

Smoking has been shown to be not dangerous at all. 

-- Dr. Marlboro

In some recent scientific articles, people with normal limbs asking for amputations have been tagged with the diagnosis Xenomelia  [1][2]. Now, advocates say that this is a logical and ethical justification to go for amputation.

Yeah, I figured that one would capture your attention.

The outstanding feature of Xenomelia (or Xenomelia, Apotemnophilia or Body Identity Integrity Disorder) is proposed to be a structural variation of the brain's parietal lobe. There are some high tech articles claiming "sound people" would now "ask for healthy limbs to be amputated" such as by Paul Hochman of Fast Company. Really, these people probably just have a disorder and should get treatment.

A range of follow-up news articles cite this study and say that based on that, it would be logical and ethical to follow through with amputating these people's limbs. Even an article in NZZ am Sonntag titled "Glücklich ohne Bein" follows through with can be, at best, termed nonsense.

Obviously, it is neither logical nor ethical to amputate healthy body parts. Quite simply, it is expensive, dumb, painful, useless and impractical. Anyone who just wants that for a healthy limb must be delusional to say the least.

Parietal lobe abnormalities caught on fMRI are not new to science though. People with surprising ideas may have all kinds of brain changes. That does not mean society has to follow through with any single one of them. Just to put the record straight here.

Parietal lobe malfunction, now, is typically attributed to schizophrenia [3][4]. Disorders of body image generally [5][4] also appear to be localized there.

As most of what the so-called "healthy" people that want to have a limb amputated say about the issue is, in fact, plain nonsense (and it is not hard to realize that), we must ask ourselves the question whether there do exist specific forms of delusional disorders, and secondly, how to go about these. There definitely is something wrong with these people, and their issues should be taken seriously by any doctor who is confronted with these, but it surely makes sense to be somewhat careful with that type of data.

Logic and ethics challenge

If a schizophrenic patient with proven parietal lobe thinning feels the frequent urge to swallow scalpels, no doctor would consider prescribing scalpels to the patient as a logical or ethical consquence. Much rather, one would try to get the patient to stop what, to anyone else, clearly appear to be dumb actions of self harm.

If a delusional patient with structural parietal lobe damage feels the urge to pack all of their belongings, books, valuables and documents into trash bags and then throw them away just to awaken from the delusion into a world where they have been stripped of all their belongings, it may not be just such a great idea for doctors to prescribe more trash bags and unsupervised room for more hallucinations, maybe also at the doctor's private home, who knows, for that patient either. Because with all due respect for the need to clean out attics and the likes, such activities are safe to call "crazy".

If the heart is ill, best to treat the heart (not amputate limbs even though that might reduce some cardiac afterload). So, if the brain appears to be the problem, best to target the brain with treatment (not amputate limbs).

If a patient asks for something, they might do so for good reasons as seen from the point of view of others. If a patients asks for something, however, they are maybe also out of their mind. The art consists in telling these apart. It would be ethical to be reluctant here. Based on what we know about parietal lobe variations so far, the likelihood of a patient exhibiting psychiatric symptoms is higher - regardless of how normal that person thinks they are themselves. Lack of insight also can be a symptom, a problem.

That much must be clear to any streetwise person with access to Google.

The danger

There are a number of dangers at large here.

  • Amputation can and will have a bunch of quite serious consequences to the amputee - social issues that are severe, pain issues that are severe, financial issues that range between serious and devastating, skin issues that can be chronic or even progressive, complications that range from added damage - other joints, spine, et cetera - to failure related issues (inability to clean properly, inability to drive safely, et cetera).
  • Amputating people with under-researched psychiatric diagnoses, as a doctor, is probably the dumbest thing one can do ever. This doesn't mean amputation doesn't have a role in treating people with damaged extremities of any kind - but to remove a healthy leg from a person with radiologically proven temporal lobe damage, that's outright dumb. Wait until there's a drug out to remedy the situation, or just send them home and tell them to stay put.
  • Swiss disability insurance rejects claims of people with chronic pain because "the chronic pain cannot be proven" even though there might be a correlate. They have to go and work. There is no financial support for people with chronic pain. This tells us that within the framework of medical diagnoses, there does exist stuff that may be extremely uncomfortable to bear - but it is not society's or an insurance's role to bear it. It is the patient that suffers pain, so the patient suffers the consequences of having a diagnosis that insurance does not recognize for financial support. They will in all likelihood cover pain killers but not provide financial support so people suffering pain can stay at home. Along the same line, my phantom pains do not provide any reason for me to get anything - let alone work less and stay home. I, as well as other folks, do suck it up. And as long as a considerable amount of people have to suck up stuff that is outside a hard and narrow definition of what insurances pay, schizophrenics, body dysmorphia victims, and whoever else also have to suck up a major part of their problems. That may be seen as unfortunate. But such practices also define a practical reality.

The real question

This now warrants the question what the hell is wrong with all these other people. The ones that perpetuate the idea that following through with some delusional directions given by possibly ill and deluded, parietally challenged folks.

[1] [doi] L. M. Hilti, J. Hänggi, D. A. Vitacco, B. Kraemer, A. Palla, R. Luechinger, L. Jäncke, and P. Brugger, "The desire for healthy limb amputation: structural brain correlates and clinical features of xenomelia," Brain, vol. 136, iss. 1, pp. 318-329, 2013.
[Bibtex]
@article{hilti2013,
author = {Hilti, Leonie Maria and Hänggi, Jürgen and Vitacco, Deborah Ann and Kraemer, Bernd and Palla, Antonella and Luechinger, Roger and Jäncke, Lutz and Brugger, Peter}, 
title = {The desire for healthy limb amputation: structural brain correlates and clinical features of xenomelia},
volume = {136}, 
number = {1}, 
pages = {318-329}, 
year = {2013}, 
doi = {10.1093/brain/aws316}, 
abstract ={Xenomelia is the oppressive feeling that one or more limbs of one’s body do not belong to one’s self. We present the results of a thorough examination of the characteristics of the disorder in 15 males with a strong desire for amputation of one or both legs. The feeling of estrangement had been present since early childhood and was limited to a precisely demarcated part of the leg in all individuals. Neurological status examination and neuropsychological testing were normal in all participants, and psychiatric evaluation ruled out the presence of a psychotic disorder. In 13 individuals and in 13 pair-matched control participants, magnetic resonance imaging was performed, and surface-based morphometry revealed significant group differences in cortical architecture. In the right hemisphere, participants with xenomelia showed reduced cortical thickness in the superior parietal lobule and reduced cortical surface area in the primary and secondary somatosensory cortices, in the inferior parietal lobule, as well as in the anterior insular cortex. A cluster of increased thickness was located in the central sulcus. In the left hemisphere, affected individuals evinced a larger cortical surface area in the inferior parietal lobule and secondary somatosensory cortex. Although of modest size, these structural correlates of xenomelia appear meaningful when discussed against the background of some key clinical features of the disorder. Thus, the predominantly right-sided cortical abnormalities are in line with a strong bias for left-sided limbs as the target of the amputation desire, evident both in our sample and in previously described populations with xenomelia. We also propose that the higher incidence of lower compared with upper limbs (∼80% according to previous investigations) may explain the erotic connotations typically associated with xenomelia, also in the present sample. These may have their roots in the proximity of primary somatosensory cortex for leg representation, whose surface area was reduced in the participants with xenomelia, with that of the genitals. Alternatively, the spatial adjacency of secondary somatosensory cortex for leg representation and the anterior insula, the latter known to mediate sexual arousal beyond that induced by direct tactile stimulation of the genital area, might play a role. Although the right hemisphere regions of significant neuroarchitectural correlates of xenomelia are part of a network reportedly subserving body ownership, it remains unclear whether the structural alterations are the cause or rather the consequence of the long-standing and pervasive mismatch between body and self.}, 
URL = {http://brain.oxfordjournals.org/content/136/1/318.abstract}, 
eprint = {http://brain.oxfordjournals.org/content/136/1/318.full.pdf+html}, 
journal = {Brain} 
}
[2] [doi] A. Aoyama, P. Krummenacher, A. Palla, L. M. Hilti, and P. Brugger, "Impaired Spatial-Temporal Integration of Touch in Xenomelia (Body Integrity Identity Disorder)," Spatial Cognition & Computation, vol. 12, iss. 2-3, pp. 96-110, 2012.
[Bibtex]
@article{aoyama2012,
author = {Aoyama, Atsushi and Krummenacher, Peter and Palla, Antonella and Hilti, Leonie   Maria and Brugger, Peter},
title = {{Impaired Spatial-Temporal Integration of Touch in Xenomelia (Body Integrity Identity Disorder)}},
journal = {{Spatial Cognition & Computation}},
volume = {12},
number = {2-3},
pages = {96-110},
year = {2012},
doi = {10.1080/13875868.2011.603773},

URL = {http://www.tandfonline.com/doi/abs/10.1080/13875868.2011.603773},
eprint = {http://www.tandfonline.com/doi/pdf/10.1080/13875868.2011.603773},
abstract = { Abstract Body integrity identity disorder (BIID), or xenomelia, is a failure to integrate a fully functional limb into a coherent body schema. It manifests as the desire for amputation of the particular limb below an individually stable ‘demarcation line.’ Here we show, in five individuals with xenomelia, defective temporal order judgments to two tactile stimuli, one proximal, the other distal of the demarcation line. Spatio-temporal integration, known to be mediated by the parietal lobes, was biased towards the undesired body part, apparently capturing the individual's attention in a pathologically exaggerated way. This finding supports the view of xenomelia as a parietal lobe syndrome. }
}
[3] M. Yildiz, S. J. Borgwardt, and G. E. Berger, "Parietal lobes in schizophrenia: do they matter?," Schizophr Res Treatment, vol. 2011, p. 581686, 2011.
[Bibtex]
@Article{yildiz2011,
   Author="Yildiz, M.  and Borgwardt, S. J.  and Berger, G. E. ",
   Title="{{P}arietal lobes in schizophrenia: do they matter?}",
   Journal={{Schizophr Res Treatment}},
   Year="2011",
   Volume="2011",
   Pages="581686",
   url={http://www.hindawi.com/journals/sprt/2011/581686/}
}
[4] [doi] S. A. Spence, "All in the mind? The neural correlates of unexplained physical symptoms," Advances in Psychiatric Treatment, vol. 12, iss. 5, pp. 349-358, 2006.
[Bibtex]
@article{spence2006,
author = {Spence, Sean A.}, 
title = {{All in the mind? The neural correlates of unexplained physical symptoms}},
volume = {12}, 
number = {5}, 
pages = {349-358}, 
year = {2006}, 
doi = {10.1192/apt.12.5.349}, 
abstract ={Physical symptoms with no medical explanation are commonly experienced by healthy people and those attending clinics. Psychiatrists see such patients in liaison settings and clinics for those with psychotic and affective disorders. The pathophysiology remains obscure; physical investigations are usually performed to exclude pathology rather than elucidate dysfunction. However, modern neuroimaging has allowed the study of nervous system structure and function. Although there are few diagnostically specific findings, patterns of association have emerged: where action is impeded (certain forms of conversion disorder and chronic fatigue syndrome) frontal systems of the brain are often implicated; when subjective awareness of the body is disturbed (passivity phenomena and anorexia nervosa) temporo-parietal cortices appear to be dysfunctional. The caudate nuclei (components of the frontal executive circuit) are implicated in a variety of syndromes (including body dysmorphic disorder, somatisation and chronic fatigue). The brain may be viewed as a cognitive neurobiological entity, crucially oriented towards action (for survival). Psychiatric syndromes that have an impact on bodily awareness signal dysfunction within systems representing that body and its performance in time and space.}, 
URL = {http://apt.rcpsych.org/content/12/5/349.abstract}, 
eprint = {http://apt.rcpsych.org/content/12/5/349.full.pdf+html}, 
journal = {{Advances in Psychiatric Treatment}}
}
[5] P. D. McGeoch, D. Brang, T. Song, R. R. Lee, M. Huang, and V. S. Ramachandran, "Xenomelia: a new right parietal lobe syndrome," J. Neurol. Neurosurg. Psychiatr., vol. 82, iss. 12, pp. 1314-1319, 2011.
[Bibtex]
@Article{mcgeoch2011,
   Author="McGeoch, P. D.  and Brang, D.  and Song, T.  and Lee, R. R.  and Huang, M.  and Ramachandran, V. S. ",
   Title={{{X}enomelia: a new right parietal lobe syndrome}},
   Journal={{J. Neurol. Neurosurg. Psychiatr.}},
   Year="2011",
   Volume="82",
   Number="12",
   Pages="1314--1319",
   Month="Dec"
}

Cite this article:
Wolf Schweitzer: Technical Below Elbow Amputee Issues - Is our society slightly off? Whoever recommended amputation of healthy limbs?; published 11/03/2013, 03:13; URL: https://www.swisswuff.ch/tech/?p=1486.

BibTeX: @MISC{schweitzer_wolf_1602828122, author = {Wolf Schweitzer}, title = {{Technical Below Elbow Amputee Issues - Is our society slightly off? Whoever recommended amputation of healthy limbs?}}, month = {March},year = {2013}, url = {https://www.swisswuff.ch/tech/?p=1486}}