• Notes unwillingness to disclose condition, need of high degree of suspicion to assess patients, and complicated risk assessment make diagnosis challenging

BY Ruwan Laknath Jayakody Since clinical vampirism is rarely reported, it may go unnoticed during assessment as patients may not willingly disclose their urge to drink blood, and therefore a high degree of suspicion is needed during the assessment of patients with substance misuse and self-inflicted injuries, while associated dissocial personality traits may complicate the risk assessment and subsequent management thereof. These observations were made in a brief report on “Vampires! Do they exist? A case of clinical vampirism” which was authored by D.R.S. Adicaram, E.S. Wijayamunige, and S.C.A. Arambepola (all attached to the National Hospital, Kandy) and published in the Sri Lanka Journal of Psychiatry 12 (2) in December 2021. European folklore describes vampires as reanimated corpses that seek nourishment from sucking blood from sleeping people (“Clinical vampirism” by R.E. Hemphill and T. Zabow). Adicaram et al. noted that in psychiatry, accounts related to vampires have, in the absence of psychotic illnesses, been described in the form of vampiric delusions in schizophrenia (a chronic and severe mental disorder and illness involving psychosis, characterised by distortions in thinking, perception, emotions, language, sense of self, and behaviour, with hallucinations and delusions being experienced) or disturbed behaviours of people, due to the compulsion of drinking blood. Psychiatric literature collectively described these conditions under the term “clinical vampirism” which is however not incorporated as a diagnostic category in the International Statistical Classification of Diseases and Related Health Problems 10th Revision or the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition classification systems, or per B.D. Kelly, Z. Abood, and D. Shanley’s “Vampirism and schizophrenia”.  Clinical vampirism has been further classified as follows (H. Prins’s “Vampirism – A clinical condition”): 1. Complete vampirism involving the ingestion of blood, necrophilic activity, and necro sadism; 2. Vampirism in which blood ingestion or dead flesh consumption is not evident; 3. Vampirism without death being involved; or 4. Auto-vampirism which involves the ingestion of one’s own blood including through a) self-induced bleeding with the ingestion of blood, b) voluntary bleeding with the re-ingestion of blood, or c) auto-haemo fetishism where the sight of blood in a syringe drawn up during the intravenous drug addictive practice evokes pleasure, mostly of a sexual nature. Adicaram et al. presented a local case report in this regard. A 20-year-old single, unemployed, male was referred from a drug rehabilitation centre to a psychiatry clinic. He presented with poor anger control, impulsive behaviour, and the urge to drink blood, against a backdrop of dependence on multiple substances. He had been adopted in his early childhood. There were no childhood features to suggest developmental delays, hyper activity, impulsivity, or conduct disorder. Although he had failed all the subjects in the General Certificate of Education Ordinary Level (GCE O/L) examination, he was literate and was able to handle money.  At the age of 16, he had started consuming alcohol, cannabis, pregabalin (anti-convulsant and anxiolytic [used to reduce or relieve anxiety] medication), diazepam (of the benzodiazepine family that acts as an anxiolytic), and tramadol (opioid pain medication). One year later, he had started using heroin and eventually came to become dependent on the above substances. He had started to develop affiliations with many gangs and had got involved in many fights. At the age of 16 years, after a fight, he had started to lick the blood on his arms. He reported that he had done this about 40 times. He claimed that he had not attacked people in search of blood, but that whenever the opponent was bleeding, he had tasted the blood of the opponent. He had frequent encounters with law enforcing authorities due to various illegal activities such as stealing and peddling heroin and he did not express remorse regarding this. Two years ago, he had started the intravenous use of heroin and habitually drank a syringe of blood before injecting heroin. If he was not satisfied with his own blood, he would ask his friends to draw blood for him. Eventually, he developed the urge to drink blood whenever he heard about blood or saw blood on television. Although he experienced a sense of satisfaction after the ingestion of blood, this act was not associated with obsessions, delusions, hallucinations, sexual gratification, or paraphilic behaviour.  He did not have any other psychiatric illnesses. During his stay in the rehabilitation centre, he did not engage in the ingestion of blood until two weeks prior to the presentation, when he had seen the wound of an inmate. He had licked the blood in that wound. He had also cut his own forearm superficially with a blade, and drunk his blood, following which he was referred to the psychiatric clinic. His medical and surgical histories were uncomplicated. On examination, he had multiple self-inflicted cut injuries over the left forearm and thickened veins over the left cubital fossa (a small triangular area located on the anterior surface of the elbow).  His mood was euthymic (without mood disturbances), the cognitive functions were intact and he had partial insight regarding this. He was keen to take treatment because his partner had rejected him after witnessing his odd behaviour. Basic investigations, non-contrast computerised tomography brain, electro-encephalogram report, and venereology assessment did not reveal any abnormality. His intelligence quotient, as assessed by the Test of Nonverbal Intelligence – Three was below average. During his hospital stay, the patient was treated with an atypical antipsychotic used to treat certain mental and mood disorders, an antidepressant of the selective serotonin reuptake inhibitor class, a carbonic anhydrase (an enzyme that catalyses the removal of a water molecule from a compound) inhibitor medication used to treat certain types of seizures, a first generation antihistamine (medicine often used to relieve symptoms of allergies), and antipsychotic used to treat allergies and nausea. He was also taught relaxation techniques, and anger and impulse control strategies using mindfulness, motivational enhancement therapy, and cognitive behaviour therapy for heroin dependence.  He was referred to a forensic psychiatrist and his risk to others was discerned to be low, and forensic psychiatric interventions were not deemed necessary. The patient was included in the high risk register and was followed up on in the clinic. Discussing the case, Adicaram et al. explained that the patient was diagnosed as having mental and behavioural disorders due to the use of multiple substances, and that he was currently in remission, while also having mild mental retardation and dissocial personality disorder. According to the classic description of clinical vampirism, he was having vampirism without death being involved, and it was not secondary to a psychotic illness and his behaviour was not a result of an obsession, since the idea and the execution of blood ingestion was not distressing. Prins and “Clinical vampirism: A review and illustrative care report” by K. Gubb, J. Segal, A. Khota, and A. Dicks had reported that mental retardation is associated with vampirism, and also that when vampirism is embedded in an antisocial personality disorder, subjects may present with childhood impulse control difficulties, the early tendency to violate rules, and the lack of empathy towards others. However, Adicaram et al. observed that the existing literature does not provide substantial evidence for the definitive management of this condition. Adicaram et al.’s management of this patient focused more on helping him control his substance misuse and associated issues, with which management, his blood drinking behaviour, anger, and impulse control improved. Subsequently, the patient had stopped the consumption of psychoactive substances. It is important, Adicaram et al. noted, to increase awareness of this condition, which though very rare, may have grave forensic implications. If you’re affected by the above content or if you/someone you know may be dealing with a similar situation, the following institutions would assist you: The National Institute of Mental Health: 1926 NDDCB emergency hotline: 1927 Mel Madura (Sumithrayo): 0112694665