More work is needed to explain why patients ask for amputation of healthy limbs

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7242.1147/a (Published 22 April 2000) Cite this as: BMJ 2000;320:1147
  1. Keren Fisher, consultant clinical psychologist,
  2. Robert Smith, consultant general surgeon
  1. Psychology Department, Royal National Orthopaedic Hospital Trust, Stanmore, Middlesex HA7 4LP

    EDITOR—Dyer reports that a surgeon in Scotland amputated the legs of two psychologically disturbed men who had nothing physically wrong with the limbs.1 There are several discrete groups of patients requiring such amputation, the most relevant being the group with a mismatch between their actual and perceived body schema. We have studied the psychological processes of seven such patients and have had correspondence with three others. We have used standardised mental health instruments and a technique to explore the expected self image with and without an amputation in relation to liked and disliked aspects of the self and partners.

    The results of this assessment indicated that these patients do not have any known psychiatric illness and are a different group from people who fantasise about limb loss as an aid to sexual arousal. They seem to have some similarities to transsexuals, whose main concern is with body shape and gender identity.2 The conviction has been there since childhood that the body does not have the right appearance to match its cortical representation, and the limb seems not to belong. This is not the same as body dysmorphic disorder, in which the limb is regarded as ugly; it is regarded as normal but is in some way surplus to the perception of the complete body. As was stated in Dyer's article, patients who have had surgery have reported a better quality of life once the effort involved in seeking a solution is removed.

    The patients that we have studied have also been assessed by two psychiatrists and in some cases have previously undergone extensive psychiatric treatment. This has not influenced the perceived discrepancy between the physical and mental representation of the body.

    Perceived reduplication of normal limbs may occur in some neurological conditions,3 and people with congenital limb deficiency may experience phantom sensations in the absent limbs.4 Clearly, therefore, the phantom and the physical body do not always have complete correspondence. In patients requesting amputation to correct a perceived abnormality the opposite situation may have occurred: the physical limb has developed but the sensory awareness of it is lacking in some important respect. Thus it becomes not a psychiatric but a neuropsychological problem. Further research may enable us to explain this more fully.


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