Body Modification and Personality: Intimately Intertwined?

Many psychiatric residents will encounter patients who modify their bodies. Body modification (e.g., tattooing, non-earlobe piercing) can incite many reactions in the observer and can often be a source of stereotyping. An oft-repeated mantra is that possession of significant body modifications (≥1 tattoo or multiple non-earlobe piercings) is suggestive of the presence of a personality disorder in the bearer (1–3). The veracity of this claim is difficult to substantiate anecdotally. Additionally, public perception of body modification continues to change (4).

Up to 20% of U.S. adults bear at least one tattoo (5). Therefore, it is unclear whether body modification has experienced some acculturation or whether possession of modifications still suggests character pathology. The body of literature examining body modification and its relation to personality is large. The present review focuses on the origins of early beliefs and how these may be challenged with more recently published literature.

History

The oldest examples of body modification date from the Egyptian Middle Kingdom (ca. 2000 BC). Tattooing during this era was reserved for those of high standing, and in fact, navel piercing was routinely used as a sign of royalty (6). Purposeful passage of pointed instruments through appendages was harnessed by classical Mayan civilization (ca. 250–1000 AD) in religious ceremonies. The blood released by these temporary body modifications was used to adorn penitent followers and to demonstrate the virility of holy practitioners (7).

What then caused a change from desirable to deviant? In three great voyages (1768–1780), Captain Cook, a British explorer and cartographer, made the first recorded European contact with the Hawaiian islands and in eastern Australia. He and his crew repeatedly encountered the people of Polynesia, among whom tattooing was prevalent. Tattooing in the South Pacific then served to mark cultural rites of passage, affiliation to one’s kin, and identification of one’s enemies. Indeed, the modern word “tattoo” descends from the Polynesian word “tatua,” meaning “artistic” (1). Cook’s men were amazed with these tattoos, with some even choosing to have the same tattoos inscribed on themselves. Upon their return to Europe, which at the time was largely unfamiliar with body modification, such flaunted markings instantly drew admiration. A perceived link between body modification and exotic locales then encouraged select European nobility to undergo modification as well (7).

Over the next 100 years, body modification, especially tattooing, became more and more synonymous with the mariner and the lower socioeconomic classes that seamen inhabited (7). The invention of the electric tattoo gun in the late 1800s further democratized tattooing (8), and as the prevalence of tattoos in the lower socioeconomic classes increased, the desirability of body modification in the upper socioeconomic classes decreased. From the perspective of the upper class, tattoos grew to symbolize the homogeneity of the working masses (7). Ease of tattooing allowed it to be co-opted into criminal identification schemes as well. Thus, by the early 20th century, body modification had become a mark of social deviance (7).

Perceptions in the 20th Century

In the early 20th century, both medical practitioners and psychiatrists were integral in linking body modification with presumed characterological deficits. The presence of body modifications was identified in “prostitutes and perverts” by the psychiatrist Parry in 1934 (9), and body modifications noted during indoctrination physicals of American World War II conscripts were found to be associated with higher rates of rejection for service (43.8% versus 29.9%). These rejections in tattooed conscripts were more likely to result from “neuropsychiatric reasons,” including “psychopathic personality” and “mental defect.” Such findings led Lander and Kohn (3), the examining doctors, to state that “there is thus a correlation between … tattoos and the presence of significant psychopathology,” a finding subsequently publicized in Time magazine (10).

Further studies in the 1950s and 1960s presented evidence that linked the possession of multiple tattoos to underlying disorders of personality. In a series of works examining hospitalized psychiatric and general medical patients (in aggregate: tattooed, N=111; not tattooed, N=609), Gittleson and colleagues (2, 11) reported an elevated prevalence of personality disorders in those who were tattooed (25% of patients) compared with those who were not (8% of patients) (2). The specific personality disorder diagnoses in those tattooed was not fully delineated in early reports, but in the 1990s Inch and Huws (12) presented a series of cases that conceptualized tattooing and other body modifications as being a manifestation of borderline personality disorder.

Retrospectively, it is difficult to disentangle the relative contributions of social stigma against body modification on the one hand and objective medical reporting on the other, in the formation of a firm opinion relating body modification and personality. It is also difficult to determine how much the countercultural nature of body modification may have enriched the prevalence rates of personality disorders in the tattooed population, as tattooed persons may have already been more culturally non-conformist in nature to begin with. What is clear is that most of the previous centuries’ work was based on case series or on enriched samples of psychiatric inpatients. Limited data were collected from other, broader segments of society, especially those without documented psychiatric diagnoses.

A Change?

A 2000 study reported by Rooks and colleagues (13) was one of the first to report data from a patient population broader than psychiatric inpatients alone. In a consecutive 2-day survey of all patients presenting to a community hospital emergency department, the presence of tattoos was recorded, as well as the primary reason for presentation (a tripartite outcome of injury, illness, or psychiatric/chemical dependency). Although 16% of patients reported possessing at least one tattoo, the investigators were unable to find a correlation between possession of a tattoo and the reason for presentation to the hospital (12). Although this study, due to its design, was unable to definitively disprove a link between tattoos and the presence of a personality disorder, it did provide evidence beyond the scope of the previous works of Gittleson and colleagues (11). While it may be that possession of body modifications has little to do with the reason for patient presentation for acute care, the dissonant results of these two studies focuses attention on the changing perception of body modification over 30 years.

An additional study by Hohner and colleagues (14) examined the link between the presence of borderline personality traits and body modification. In a sample of 289 women with body modifications, a group manifesting borderline personality traits was identified and then compared with the remaining women who did not manifest these same personality traits. No difference was found in the number or nature of body modifications between the two groups. While a definitive conclusion on the relation between borderline personality disorder and body modification awaits more rigorously designed studies, the work of Hohner and colleagues (14) highlights that the number and type of body modification were not useful discriminators in a modern cohort of women. When compared with the work of Inch and Huws (12), the evidence presented by Hohner and colleagues also suggests that a re-evaluation of previously held assumptions about body modification and personality may be topical.

The above studies highlight potential changes in the diagnostic implications of body modification in a more general population. Ongoing work in forensic settings has suggested that a link between specific personality traits and body modification may be relevant. Detailed study of 36 male forensic patients conducted by Cardasis (15) revealed that significantly more patients with tattoos had a diagnosis of antisocial personality disorder compared with patients without tattoos. Additionally, patients with antisocial personality disorder had a greater number of crudely or self-applied tattoos and a tendency toward having a greater percentage of their total body surface area tattooed. Unfortunately, neither this study nor other more recent works have addressed the diagnostic implications of full-arm “sleeve-type” tattoos. Future studies on this topic could be informative.

Conclusions

The last 75 years have seen significant change in the societal perception of body modification (16). While initial psychiatric and medical studies placed emphasis on the diagnostic utility of body modifications in identifying personality disorders, studies in broader groups of patients have generated some challenge to long-promulgated diagnostic links between body modification and personality disorders. At the same time, studies in the forensic setting have refined this diagnostic link in a specific population and suggested that antisocial personality disorder must be carefully ruled out in those forensic patients who possess large numbers of crudely applied or self-made tattoos or who have a large area of their body covered by tattoos. While initially seeming contradictory, these two disparate views of body modification are in fact complementary and help to make the resident’s understanding of the link between body modification and personality disorder more sophisticated than it was in the previous century. Anchoring quickly on personality dysfunction in a body modifier now seems premature, and it is advisable to consider body modification more as a signal for further inquiry (17), especially if there is a forensic history. A better understanding not only of coping style and life course, but also reasons for body modification, should help the resident to avoid the rapid application of a diagnosis that can be ultimately difficult to remove if erroneous.

Key Points/Clinical Pearls