East Asian Arch Psychiatry 2013;23:164-7

CASE REPORT

苏玮琳、梁志明

Dr Jane So, MBBS, Department of Psychiatry, Shatin Hospital, Hong Kong SAR, China.
Dr Chi-Ming Leung, MRCPsych, FHKCPsych, FHKAM (Psychiatry), Department of Psychiatry, Shatin Hospital, Hong Kong SAR, China.

Address for correspondence: Dr Chi-Ming Leung, Department of Psychiatry, Shatin Hospital, Hong Kong SAR, China.
Tel: (852) 2636 7754; Fax: (852) 2647 5321; Email: cmleung@ha.org.hk

Submitted: 5 March 2013; Accepted: 22 July 2013

pdf Full Paper in PDF

Introduction

The word ‘mummification’ is derived from the Latin word‘mumia’, which means black bitumen — the substance used for preservation of the body after death in Egypt. However, in psychiatry, mummification is not a religious ritual but a symptom presenting in a minority of patients suffering from grief. Mummification was described by Gorer in 1965 as a grief reaction in which the deceased individual’s belongings and, in extreme cases, his or her corpse are preserved as if he or she was still alive,¹ and often the grieving person acts as if the deceased will return at a later date.² Mummification is often regarded as a pathological phenomenon in western psychiatric literature.

Little research has been done on the cultural differences of patients demonstrating mummification. In the Asian community, a common belief is that there is life after death. The spirits of the dead are believed to exist in the human world, and it is not uncommon for people to burn paper offerings to provide spirits with the comforts required for the afterlife. Taking into account these beliefs, this report discusses a case of grief in a Chinese patient that raised questions about the psychopathology behind this phenomenon and whether mummification is always a morbid symptom in the Chinese population. 

Case Report

A 60-year-old man presented to the psychiatric outpatient clinic at Prince of Wales Hospital with depression in March 1996. His wife had a terminal brain tumour and the patient had chosen palliative care with no further surgical intervention. He presented with a history of insomnia since the diagnosis of his wife’s condition. He also demonstrated other depressive symptoms, including persistent low mood, anhedonia, and feelings of guilt, hopelessness, and worthlessness. He denied having suicidal ideas, but expressed that life was no longer meaningful. He sometimes heard his wife’s footsteps around the house, but claimed that he knew that they were not real. He denied having psychotic symptoms and had no history of manic symptoms. He was diagnosed with depression, and was consequently referred to the clinical psychologist and given antidepressant, paroxetine 20 mg orally per day. After the death of his wife, his depressive symptoms worsened. He only slept for 1 to 2 hours each night and had frequent crying spells at home. He mostly stayed at home organising photos of his wife and repeatedly watching home videos.

Six months after the death of his wife, it was revealed that the patient had ‘mummified’ his wife’s room. A home visit was paid to observe the patient’s living environment. He had kept all of her possessions, including personal hygiene products, in their original positions and placed each of her garments into individual plastic bags for better preservation. He turned on the radio in his wife’s room when he went out for meals. He had also started making a life-size doll to resemble his wife. He appeared to be cheerful and proud of his accomplishment as he described in great detail his efforts to buy the correct materials and cloths to produce the most realistic doll possible. He did not sleep with the doll, but described feeling comforted when he fondled and looked at the doll in the middle of the night. He sometimes talked to the doll, mainly asking it to give him a sign if the spirits were real. The patient claimed that he understood that his wife had died, but felt that he could not control his response or actions towards her death. He claimed that he believed the doll was not alive and remarked that making the doll was a 3-dimensional form of commemoration instead of the 2-dimensional form of photos. He felt that the doll brought him closer to his wife. He questioned whether spirits existed and hoped that, if they did, his wife’s spirit would be pleased with the way he had preserved her belongings and made the doll to commemorate her, and possibly communicate with him via the doll. After finishing the doll, the patient actively engaged in voluntary work at an old-age home. The patient’s son, an educated man in his early forties, did not express particular worry over his father’s behaviour and instead expressed understanding of the production of the doll.

The patient had no family history of mental illness or suicide. He had been born and raised in Hong Kong, and was educated to secondary level. The patient had good relationships with his 4 children. His pre-morbid personality was described by his children as being responsible, organised, and not pessimistic or superstitious. His main interest was spending time with his wife. He had no formal religious beliefs. However, his older relatives practised ancestor worship, a custom of making paper dolls of the deceased after their deaths and burning them as a form of offering.

The patient was treated for depression with antidepressant, citalopram 20 mg orally per day and psychotherapy. He was irregular with follow-up but made a full recovery after 2 years. He was no longer depressed and his insomnia improved. He stopped looking at his wife’s photographs and home videos. He donated his wife’s clothes to the Salvation Army and threw away the doll approximately 1 year later. He later expressed that his previous behaviour was a result of being “out of his mind with grief”.

Discussion

This patient demonstrated an extreme form of mummification, with features including persistent low mood, crying spells, feelings of guilt, disturbed sleep, and pseudohallucinations (hearing the deceased’s footsteps) that lasted for more than 1 year. Mummification has been recognised by the western literature to be a morbid grief reaction.³ Gorer¹ suggested that mummification was a maladaptation of unresolved grief in a ritual-less society. In other words, Gorer believed that mummification originated from the lack of rituals in society, meaning that people in grief had to turn to their own rituals to cope with their bereavement. While this may possibly be true in western society, this theory does not necessarily comply with Chinese practices.

The rituals involved in mourning the dead are well developed in Chinese society, and can be traced in the teachings of Confucius, whose philosophy is still often quoted as a guideline to modern day ethics. It was mentioned in Confucius’ Analects that the practice of mourning should be for a period of 3 years（守孝三年）after the death of a parent,⁴ where the grieving person was expected to put aside his or her affairs to be managed by others and devotes the period of mourning to meditation and spiritual communion with the deceased. The practice remained popular until the Qing Dynasty. In Hong Kong, most death rituals are derived from Daoist beliefs.⁵ Daoists believe that each human has both hun（魂）and bo（魄）. The 7 bo souls leave the body after death to the underworld with the possibility of immortalisation. The well-practised ritual ‘Return of the Soul’（回魂）in the Chinese community in Hong Kong refers to the return of the hun soul to the family home after death. The patient in this report had similar beliefs regarding his wife’s soul; he believed that her soul would return to their home after death and hence, he preserved her room and produced the doll as a form of spiritual worship.

Another example of Chinese beliefs regarding spirits and souls can be demonstrated in the architecture of traditional Chinese graves. While a western grave may simply be marked by a tombstone to commemorate the deceased, traditional Chinese graves represent ‘yin houses’（陰宅）for the afterlife of spirits⁶ (the living reside in ‘yang houses’ [陽宅]). Traditional Chinese graves can still be found in rural areas of Hong Kong. These graves were built as homes for the spirits of the dead, and this is reflected in the large house-like structures of gravestones protecting the ashes or bodies of the deceased. Considering that this patient was raised in a society influenced by Chinese culture, the Chinese beliefs regarding the afterlife contributed significantly to his actions after the death of his wife. It is thus questionable whether his actions, albeit with full-blown features of mummification, should be treated as morbid symptoms of his grief.

Consideration of a patient’s cultural background is often essential in determining the morbidity of a symptom in psychiatry. Western beliefs of life after death often have Christian influences in that souls reside either in heaven or hell depending on the deceased’s faith in the God’s salvation during his or her life.⁷ Christian beliefs based on biblical teachings prohibit the worship of idols,⁸ including ancestry worship,⁹ which is often practised in Chinese culture. This contrasts with Chinese beliefs that the spirits or souls of the dead can exist in the earthly world of humans, and are not eternally inhabiting in an otherworld. Chinese culture consists of ancestry worship and mourning rituals that seek peace for the spirits of the dead. This difference, therefore, has implications for the interpretation of mummification. While western patients in grief may mummify the deceased’s environment in an act of denial of the individual’s death and wait for his or her return, Chinese patients may do so as an act of respect or reminiscence for the dead and a form of preparation for the deceased spirit’s return. This patient’s behaviour was consistent with his cultural beliefs regarding souls or spirits. Hence, the term mummification should only be considered to be morbid if it occurs in a patient with a western cultural background where earthly afterlife and ancestral worship do not exist.

Cultural influences on mummification may also be related to differences in expression of emotion. Compared with other cultures, Chinese people are generally reluctant to verbally express emotions, especially negative feelings.^10,11 Chinese patients with depression often present with somatisation,¹² which can be seen as an external representation of negative emotion. This observation could therefore be projected to this patient’s behaviour; his actions were a form of externalisation of his inner feelings. According to the patient, the doll acted as a “3-dimensional form of commemoration”. This signified his need for a more external representation of his feelings, which could not be met through 2-dimensional objects such as photographs.

Although widely described as a feature of morbid grief, there are few data on the topic of mummification. Only 2 medical papers on mummification, dating back to 1977 and 1989, were found on the database.^13,14 Both were case reports of patients who mummified the corpses of the deceased by keeping them at home after their deaths. The paper by Gardner and Pritchard¹³ discussed 6 cases in which the deceased’s bodies were kept for a period of time ranging from 1 week to 6 years, while the report by Boughton and Popkin¹⁴ focused on a patient with psychosis presenting with mummification. The form of mummification demonstrated by these patients was different from that of our patient. Firstly, the nature of the mummification described was different in that the patient did not preserve the body of his wife, as he realised that she had passed away. The production of the doll by the patient was done out of spiritual beliefs and the hope that her spirit would return to their home. The intentions behind the acts of mummification reported in the literature were that the corpses were preserved as acts of denial or were secondary to psychosis, whereas this patient preserved his wife’s belongings as a form of respect or commemoration and there was no evidence of psychotic breakdown.

As well as considering cultural beliefs in determining the morbidity of certain behaviours, we should take into account the level of distress, disruption of the patient’s functioning, and comparison of the behaviour with social norms. This patient was evidently not distressed by his act of mummification. Instead, his actions acted as a way of coping with his grief as he felt that organisation of his wife’s possessions and production of the doll would please his wife’s spirit and serve as an act of commemoration. His behaviour was also not distressing to those around him, in particular his educated son, who did not think of his father’s actions as being pathological and showed understanding for the production of the doll. The patient maintained an adequate level of functioning. Although he spent a great proportion of his time at home, he was still motivated to do household chores, go out for meals, participate in voluntary work, and maintain his personal hygiene, and there were no signs of social withdrawal from his family members and friends. While his behaviour may appear to be bizarre to some people, his reasoning for his conduct and beliefs regarding the afterlife are compatible with the cultural beliefs of Chinese society. This suggests that his behaviour could be seen as an extreme, but not necessarily abnormal version of ancestry worship and traditional mourning rituals, although even the patient later described himself as being “out of his mind” when he produced the doll.

Conclusion

Mummification should not be automatically assumed to be a symptom of morbid grief or mental illness. This patient was raised with Chinese cultural beliefs, and demonstrated that mummification may be a ritual of commemorating the deceased and a means of communicating with the dead on the premise that spirits exist. It is therefore important to consider the cultural background of every patient to understand the reasoning behind their behaviour in order to identify whether or not their actions are truly pathological.

References

1. Gorer G. Death, grief and mourning. Minnesota: Doubleday Publishing; 1965: 85.
2. Littlewood J. Aspects of grief: bereavement in adult life. London: Routledge; 1992: 57.
3. Stephenson J. Death, grief, and mourning: individual and social realities. New York: Free Press; 1985: 155-6.
4. Confucius. Analects, bk. xvii, c. xxi, v. 6.
5. Chan CL, Chow AY. Death, dying and bereavement: a Hong Kong Chinese experience. Hong Kong: Hong Kong University Press; 2006: 71-2.
6. Owen B, Shaw R. Hong Kong landscapes: shaping the barren rock. Hong Kong: Hong Kong University Press; 2007: 128.
7. Higgins JM, Bergman C. The everything guide to evidence of the afterlife: a scientific approach to proving the existence of life after death. Massachusetts: Adams Media; 2011: 22, 48-9.
8. NIV Student Bible. Michigan: Zondervan; 2002: Exodus 20:4.
9. Chapman G. Catechism of the Catholic Church. London: Geoffrey Chapman; 1999: passage 2113:460.
10. Lin TY. Psychiatry and Chinese culture. West J Med 1983;139:862- 7.
11. Hsu FL. Americans and Chinese: passages to differences. Honolulu: The University Press of Hawaii; 1976.
12. Tseng W. The nature of somatic complaints among psychiatric patients: the Chinese case. Compr Psychiatry 1975;16:237-45.
13. Gardner A, Pritchard M. Mourning, mummification and living with the dead. Br J Psychiatry 1977;130:23-8.
14. Boughton DP, Popkin MK. Mummification and folie à deux. Compr Psychiatry 1989;30:26-30.