IMPORTANT : Clinical Lycanthropy

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[size=40]Clinical Lycanthropy, Neurobiology, Culture: A Systematic Review
Sélim Benjamin Guessoum1,2,3*, Laelia Benoit1,3,4, Sevan Minassian1, Jasmina Mallet5,6 and Marie Rose Moro1,2,3
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• 1University Hospital Cochin, Greater Paris University Hospitals (AP-HP), Paris, France
  
• 2University of Paris, PCPP, Boulogne-Billancourt, France
  
• 3University Paris-Saclay, UVSQ, Inserm U1018, CESP, Team DevPsy, Villejuif, France
  
• 4Yale School of Medicine (Child Study Center), Yale University, QUALab, New Haven, CT, United States
  
• 5University Hospital Louis Mourier, Greater Paris University Hospitals (AP-HP), Paris, France
  
• 6Inserm UMR1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), Paris, France
  

Background: Culture can affect psychiatric disorders. Clinical Lycanthropy is a rare syndrome, described since Antiquity, within which the patient has the delusional belief of turning into a wolf. Little is known on its clinical or therapeutic correlates.
Methods: We conducted a systematic review (PRISMA) on PubMed and Google Scholar, until January 2021. Case reports, data on neurobiological hypotheses, and cultural aspects were included. Language was not restricted to English.
Results: Forty-three cases of clinical lycanthropy and kynanthropy (delusion of dog transformation) were identified. Associated diagnoses were: schizophrenia, psychotic depression, bipolar disorder, and other psychotic disorders. Antipsychotic medication may be an efficient treatment for this rare transnosographic syndrome. In case of depression or mania, the treatment included antidepressants or mood regulators. The neuroscientific hypotheses include the conception of clinical lycanthropy as a cenesthopathy, as a delusional misidentification of the self-syndrome, as impairments of sensory integration, as impairments of the belief evaluation system, and right hemisphere anomalies. Interestingly, there is a clinical overlap between clinical lycanthropy and other delusional misidentification syndromes. Clinical lycanthropy may be a culture-bound syndrome that happens in the context of Western cultures, myths, and stories on werewolves, and today's exposure to these narratives on cultural media such as the internet and the series. We suggest the necessity of a cultural approach for these patients' clinical assessment, and a narrative and patient-centered care.
Conclusions: Psychiatric transtheoretical reflections are needed for complementaristic neurobiological and cultural approaches of complex delusional syndromes such as clinical lycanthropy. Future research should include integrative frameworks.

Introduction

Culture can affect psychotic symptoms, and psychotic symptoms can be culturally meaningful (1, 2). The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) incorporates structured information to reflect cross-cultural variations in the presentation of psychiatric disorders (3). However, dual neuroscientific and cultural approaches are scarce. In this systematic review, we explore a specific delusional syndrome through both the neuroscientific and cultural perspectives.
Clinical Lycanthropy is a psychiatric syndrome within which the patient has the delusional belief of turning into a wolf. Zoanthropy is a psychiatric syndrome within which the patient has the delusional belief of turning into an animal. Zoanthropy is observed on all continents and animals can be lions, tigers, hyenas, sharks, or crocodiles, for example (4). Wolf transformations have been mentioned since Ancient Times in myths, in popular culture but also in the physician's observations (5). For example, in Greek mythology, Zeus transforms Lycaon, the king of Arcadia, into a wolf. The wolf has negative characteristics of a wicked and evil animal in the Western cultures and more positive ones in the Nordic cultures (6, 7). Wolves still have an important place in today's popular culture, and werewolves still are represented [e.g., Harry Potter (8), the series Teen wolf (9)].
Clinical lycanthropy is a relevant example of a challenging syndrome at the frontier between neuropsychiatric disorders and environmental, social, and cultural interactions. To which psychiatric disorders is clinical lycanthropy related? What are the neurobiological hypotheses on this syndrome? Is clinical lycanthropy related to a given cultural context? What is the management of this syndrome?
Clinical lycanthropy has been described but not elucidated since Ancient Times. A dual neuroscientific and cultural approach can help to better understand the clinical presentation of patients with psychiatric disorders and help to find relevant avenues of research.
Despite neurosciences still lacking the knowledge to explain the content of thoughts, twenty-first-century psychiatry has to take into account these themes and their cultural meaning because they are related to the patients' phenomenology, personal experience, and the patients' and families' storytelling. How would a patient adhere to a specific narrative as a delusional explanation of his/her psychotic experience? Lycanthropy is an example of a syndrome in which culture and environment are involved in the process of the neuropsychiatric disorders' clinical expression.
The objective of this systematic review is: (1) to review the reported cases of clinical lycanthropy; (2) to review the neuroscientific and etiological hypotheses on clinical lycanthropy; (3) to explore the cultural aspects of this syndrome in the medical literature.

Materials and Methods

A systematic review was conducted according to the PRISMA criteria (10). The research was led on Pubmed/MEDLINE on all available articles until January 2021 with the following words: “werewolf” OR “were-wolf” OR “lycanthropy” OR “clinical lycanthropy.” The inclusion criteria were: case reports of wolf and dog metamorphosis delusions, not restrained to the English, in the psychiatric and neurological literature. The exclusion criteria were: other animal metamorphosis delusions, non-psychiatric and non-neurological conditions referred to as “lycanthropy.” All references were screened individually (abstract ± full manuscript) to identify the case reports. Due to the scarcity of data, the case reports were included, even when they did not include data on the treatment and the outcome. Additional research was conducted on Google Scholar, and by cross-referencing the included studies and prior reviews. The cases from 1920 and earlier were extracted from Blom's review (11). The principal data collected were: age, gender, country, syndrome type, associate psychiatric diagnosis, treatment, and outcome. These data are synthesized in Table 1. There is a risk of bias due to the scarcity of case reports in the literature, and the absence of statistical data, as well as the unbalanced number of publications depending on the country. Additional analysis was led on the neurobiological hypotheses on clinical lycanthropy, and on cultural aspects available in the medical literature.

TABLE 1

[size=18]Table 1. Case reports of clinical lycanthropy and kynanthropy.[/size]
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