Syndrome

Syndrome (pronounced sin-drohm or sin-druhm)

(1) In pathology and psychiatry, a group of symptoms which together are characteristic of a specific disorder, disease or the like.

(2) A group of related or coincident things, events, actions etc; a predictable, characteristic pattern of behavior, action, etc., that tends to occur under certain circumstances.

1535–1545: From the Medical Latin syndrome (a number of symptoms occurring together), from the Ancient Greek συνδρομή (sundromḗ) (concurrence of symptoms, concourse of people), from σύνδρομος (súndromos) (literally "running together" and often used in the sense of "place where several roads meet"), the construct being συν- (syn-) (with) + δρόμος (drómos) (a running, course), best understood as syn- + dramein + -ē (the feminine noun suffix).  The meaning, beginning in 1540s medical Latin, is thus derived from the Ancient Greek syndromos (place where several roads meet); the psychological sense emerging only in 1955.  Syndrome is a noun; the adjective is syndromic.  Synonyms include malady, problem, disorder, ailment, sickness, complaint, sign, complex, infirmity, affection, symptoms, diagnostics, prognostics, all of which tend, in varying degrees, also to be applied outside the medical context.

COVID-19

Art inspired by the pandemic caused by the COVID-19 syndrome, created by medical professionals: Outsized, Overwhelming Impact of COVID-19 by Lona Mody.

COVID-19 is a syndrome and the name allocated on 11 February 2020 by the World Health Organization (WHO) for the disease caused by the coronavirus SARS-CoV-2.  Although its origin remains most associated with Wuhan in late 2019, it may have been circulating earlier.  An acronym, COVID-19 stands for COronaVIrus Disease-2019 but the original working name for the virus causing the syndrome was 2019 novel coronavirus (2019-nCoV) which the International Committee on Taxonomy of Viruses (ICTV) changed to severe acute respiratory syndrome coronavirus (SARS-CoV-2).  The name is from the standard nomenclature of the discipline, chosen because the virus is a genetic cousin of the coronavirus which caused the SARS syndrome in 2002 (SARS-CoV).  The public tends not to distinguish between virus and syndrome, the popular names being Covid and corona.

Art inspired by the pandemic caused by the COVID-19 syndrome, created by medical professionals: Pipetting the Sample by Ali Al-Nasser.

First discovered in domestic poultry during the 1930s, coronaviruses cause a range of respiratory, gastrointestinal, liver, and neurologic diseases and are common in both humans and animals.  Only seven are known to cause disease in humans, four associated with the common cold; these have the catchy names 229E, OC43, NL63, and HUK1.  The three coronaviruses which cause serious lung infections (related to pneumonia) are SARS-CoV (Severe Acute Respiratory Syndrome) first noted in 2002, MERS-CoV (Middle East Respiratory Syndrome) which emerged in 2012 and SARS-CoV-2 (the COVID-19 pandemic).

Art inspired by the pandemic caused by the COVID-19 syndrome, created by medical professionals: Naturarte by Angela Araujo.

SARS-CoV, MERS-CoV and SARS-CoV-2 are zoonotic, beginning in an animal, transmitting, either directly or via another species, to people.  SARS-CoV-2 appears to be a mutated bat virus; bats host thousands of coronavirues and exist with them mostly in symbiotic harmony and it remains unclear whether the virus passed directly from bat to human or via some other creature.  Interestingly, while the nature of the COVID-19 syndrome hasn’t changed, the SARS-CoV-2 virus has mutated and now circulates in many strains, one tending to emerge as the dominant means of transmission in a given geographical area.  The dominance of the mutated strain happened because the mutation made the virus much more infectious so, in a classic example of Darwinian natural selection, the entity able more efficiently to multiply is the one which becomes dominant.  Despite early speculation, the mutation seems not to account for reductions in the COVID-19 death rate, a phenomenon virologists attribute to improved treatment the “harvesting effect”, meaning the virus first kills those easiest to kill.  There was also the effect of many dying early in the pandemic because health systems were overwhelmed and unable to provide the treatment which would have ensured their survival.  This has been noted in past wars, epidemics, pandemics and localized disasters.

Proxy

Proxy (pronounced prok-see)

(1) The agency, function, or power of a person authorized to act as the deputy or substitute for another.

(2) The person so authorized; substitute; agent.

(3) An authorization, usually in writing, empowering another person to vote or act for the signer, as at a meeting of stockholders.

(4) An ally or confederate who can be relied upon to speak or act in one's behalf.

(5) In computing, short for proxy server.

(6) In computing, as proxy server, an interface for a service, especially for one that is remote, resource-intensive, or otherwise difficult to use directly; technically a proxy server is a piece of software but in casual use the term is often applied also to the hardware on which it’s run.

(7) In the administration of the courts of canon law, the written appointment of a proctor in suits in the ecclesiastical courts.

(8) In science, a measurement of one physical quantity that is used as an indicator of the value of another.

(9) In munitions, a slang term for a proximity device (a mine, torpedo, missile etc) which explodes when in proximity to the target, rather than having to make physical contact.

(10)In geopolitics, as proxy war, a conflict between two or more state or non-state actors conducted on behalf of or with extensive support from other parties not directly participating in the hostilities except as “advisors”

(11) In psychiatry, as Munchausen syndrome by proxy (MSbP), a mental disorder in which a factitious disorder imposed on another for the purpose of gain the attention of medical professionals.  Now technically known as 

1400–1450: From the late Middle English prokesye, proccy & procusie (agency of one who acts instead of another, office or authority of a substitute; letter of power of attorney), a contraction of the Anglo-French procuracie and the Anglo-Norman procuracy & procuration, from the Medieval Latin procuratia, from the Latin prōcūrō (I manage, administer) & prōcūrātiō (a caring for, management) from procurare (manage).  The present participle was proxying, the simple past and past participle proxied and the noun plural proxies.

The meaning "person who is deputed to represent or act for another" is from 1610s whereas of things, "that which takes the place of something else" dates from the 1630s.  The practice of proxy voting has a long history but the term appears first to have been used Rhode Island in 1664 although then it described voters sending written ballots rather than attending the election, as opposed to would now be thought a “true” proxy system, as had be used in the assembly elections of 1647.  Proxy wars date from antiquity but the term seems first to have been used in 1955, during the high Cold War.

In computing, following the proxy server, there exists a whole ecosystem of related products & protocols including caching proxy, closed proxy, complexity-hiding proxy, dynamic proxy, firewall proxy, forward proxy, open proxy, protection proxy, remote proxy, smart-reference proxy, surrogate proxy, synchronization proxy etc.  In just about any field, there seem to be proxy somethings, including proxy statement, proxy indicator, proxy measurement, proxy abuse, proxy battle, proxy bullying, proxy card, proxy marriage, proxy murder, proxy pattern, proxy voting etc.

Munchausen syndrome by proxy (MSbP)

Although the American Psychiatric Association (APA) insist the condition has been re-named factitious disorder in another (FDIA), most still prefer the more poetic Munchausen syndrome by proxy (MSbP).  It also once was called factitious disorder imposed on another FDOA) or factitious disorder by proxy (FDP) but most agree MSbP is best.  Its primary characteristic is the production or feigning of physical or psychological symptoms in another person (usually a young child or sometimes but the proxy subject can be an adult or even an animal) under the care of the person with the disorder. The symptoms are problems which are inexplicable, persistent or resistant to interventions that, based on clinical experience, would have worked, after adequate evaluation and treatment attempts.  MSbP is a variation of Munchausen syndrome (which the APA list as factitious disorder (FD)), a mental disorder in which those affected feign (or sometimes even induce) disease, illness, injury, abuse, or psychological trauma to draw attention, sympathy, or reassurance to themselves.  The name is from the fictional character Baron Munchausen from the 1785 novel Baron Munchausen's Narrative of his Marvellous Travels and Campaigns in Russia, by German author Rudolf Erich Raspe (1736-1794), a collection of extraordinary stories, based (loosely) on the tales told by the real-life Baron Hieronymus Karl Friedrich, Freiherr von Münchhausen (1720-1797).  The real baron was prone to quite some exaggeration in the tales of his travels but never went as far as Herr Raspe who included in his volume the eighteenth century baron flying to the moon.

Factitious disorder (FD) is an umbrella category including a range of mental disturbances in which patients intentionally act physically or mentally ill without obvious benefits.  The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR (2000)) distinguished FD from malingering, which was defined as faking illness when the individual has a clear motive (typically to avoid work, benefit financially or evade legal difficulties).  FD used to be known as "hospital addiction", "pathomimia" or "polysurgical addiction" and variant names for individuals with FD included "hospital vagrants", "hospital hoboes", "peregrinating patients", "problem patients" and "professional patients".

The syndrome has a long tradition.  The English physician Hector Gavin (1815-1855) in 1843 published On Feigned and Factitious Diseases in which he documented, drawing mostly from the records of soldiers and seamen, the means used to simulate or produce symptoms and the best techniques a clinician could use to of uncover impostors.  Two thousand-odd years earlier, the noted Roma physician Aelius Galenus (Galen, 129-216 AD) wrote of six cases in his journals and from then to the present, the medical literature is littered with examples but modern, systematic study didn’t really begin until 1961 when British endocrinologist and haematologist Richard Asher (1912-1969) published a paper.  It had been Dr Asher who, in 1951, had coined the term Munchausen syndrome to describe a chronic subtype of FD and his work is worth reading even by the medically untrained and otherwise uninterested, such is the vivid quality of the writing and the seductive use of language.  It was in these years that the condition began more fully to be understood as distinct from malingering and the term Munchausen syndrome most appropriately refers to the subset of patients who have a chronic variant of FD with predominantly physical signs and symptoms.  In practice, however, many still use the term Munchausen syndrome interchangeably with FD.  The American Psychiatric Association first classified Munchausen syndrome in the third edition of the DSM (DSM-III 1980) so, historically, the condition was under-diagnosed and the current view is these patients feign illness or injury not to achieve a clear benefit, such as financial gain, but rather to gain the sympathy and special attention often given to people who are truly ill.  There is often a willingness to undergo painful or even risky tests and operations in order to obtain this attention.  Munchausen syndrome is considered a mental illness but can just as helpfully be thought a symptom because it is associated with severe emotional difficulties.

The term Munchausen syndrome by proxy was in 1977 coined by British pediatrician Roy Meadow.  Meadow became famous also for the rule he published in his 1977 book The ABC of Child Abuse, which stated that in a single family, "one sudden infant death is a tragedy, two is suspicious and three is murder, until proved otherwise", this coming to be known as "Meadow's Law" and influential among UK social workers and child protection agencies.  His framing of the rule reflected his dogmatism and his reputation suffered as a consequence of his being struck from the British Medical Register by the General Medical Council (GMC) because of the erroneous and misleading evidence he provided in several trials which resulted in wrongful convictions although GMC’s ruling was overturned on appeal, on what might be described as public policy grounds.  Dr Meadow subsequently voluntarily relinquished his registration, thereby ensuring he could not be compelled to appear before the GMC regarding any previous professional conduct.

MSbP however survived the controversy.  Those with FD tend to be women aged 20-40 years and employed in medical fields such as nursing or other discipline where those employed enjoy familiarity with medical technology while those with chronic FD (Munchausen syndrome) are predominately unmarried, white, middle-aged men estranged from their families.  Perpetrators of Munchausen syndrome by proxy are typically mothers who induce illness in their young children although the conduct by fathers or others is not unknown.  The causes of FD, whether physical or psychiatric, are difficult to determine because affected patients are often lost to follow-up when they leave the hospital.  Magnetic resonance imaging (MRI) has been used and abnormalities in the brain structure of some patients with chronic FD have been detected but this does no more than suggest the possibility there may be some biological or genetic factors in the disorder shouldn’t be excluded.  The results of EEG (electroencephalography) studies are usually reported as non-specific and the suggestions for the causes of these disorders cast a wide net including (1) traumatic events and numerous hospitalizations during childhood, (2) FD allows patients to feel in control as they never did in childhood, (3) a coping mechanism, learned and reinforced in childhood and, intriguingly, (4). The “care-eliciting behaviors” theory, a process of unconscious identification with an important person, who genuinely has the pathology the patient is feigning.

Many authors have also underscored the co-occurrence of some pathological personality traits or disorders such as (5) identity disturbance, (6) unstable interpersonal relationships and (7), recurrent suicidal or self-mutilating behaviors which are similar to those encountered in borderline personality disorder.  Also noted have been instances of deceitfulness, lack of remorse, reckless disregard for safety of self, repeated failure to sustain constant work behavior and the failure to conform to social norms but these are common features not only of FD but of many antisocial personality disorders.  There is little agreement or evidence as to what causes Munchausen syndrome or Munchausen syndrome by proxy. Some theories suggest that the patient (or caregiver) may have experienced just about any of the conditions or experiences suffered by those with a variety of mental disorders and there seems to be no one thing or subset either exclusive or predictive.

In the DSM-5 (2013), the FD conditions were placed in the category Somatic Symptom and Related Disorders and the most precise definitional clauses were added, FD assigned to individuals who falsify illness in themselves or in another person, without any obvious gain  This combination of intentional falsification and lack of any obvious gain sets factitious disorder apart from similar conditions, such as somatic symptom disorder (where someone seeks excessive attention for genuine concerns) and malingering (where an individual falsifies symptoms for personal gain).  The condition is noted as both to diagnose and treat and, being rare (1% of individuals in hospital present with criteria matching the disorder), but the prevalence of factitious disorder throughout the general population is unknown.  Diagnosis of factitious disorder often requires a number of investigatory steps in order to accurately identify the condition without wrongful accusation, and treatment options can be both limited and difficult to administer if the individual refuses to admit the deception.  There are four primary criteria for diagnosing factitious disorder:

(1) Intentional induction or falsification of physical or psychological signs or symptoms.

(2) The individual presents themselves as ill, impaired or injured to others.

(3) The deceptive behavior persists even in the absence of external incentives or rewards.

(4) Another mental disorder does not better explain the behavior.

Factitious disorder may be diagnosed as either a single episode or as recurrent episodes (two or more instances of illness falsification and/or induction of injury) and Factitious disorder in another (formerly known as previously called Munchausen syndrome by proxy) may be broadly diagnosed using essentially the same four criteria as:

(1) Intentional induction or falsification of physical or psychological signs or symptoms in another person.

(2) The individual presents another individual (the victim) as ill, impaired or injured to others.

(3) The deceptive behavior persists even in the absence of external incentives or rewards.

(4) Another mental disorder does not better explain the behavior.

As with factitious disorder, factitious disorder in another may be diagnosed as either a single episode or as recurrent episodes (two or more instances of illness falsification and/or induction of injury). With factitious disorder in another, the victim may be assigned an abuse diagnosis as a result of the perpetrator’s behavior or actions.

Autophagia

Autophagia (pronounced aw-tuh-fey-juh or aw-tuh-fey-jee-uh)

(1) In cytology, the process of self-digestion by a cell through the action of enzymes originating within the same cell (the controlled digestion of damaged organelles within a cell which is often a defensive and/or self-preservation measure and associated with the maintenance of bodily nutrition by the metabolic breakdown of some bodily tissues).

(2) In cytology, a type of programmed cell death accomplished through self-digestion (known also as apoptosis and associated with the maintenance of bodily nutrition by the metabolic breakdown of some bodily tissues).

(3) In psychiatry, self-consumption; the act of eating oneself.

The construct was auto- + -phagia.  The auto-prefix was a learned borrowing from Ancient Greek αὐτο- (auto-) (self-) (reflexive, regarding or to oneself (and most familiar in forms like autobiography)), from αὐτός (autós) (himself/herself/oneself), from either a construct of (1) the primitive Indo-European hew (again) + to- (that) or (2) the Ancient Greek reflexes of those words, αὖ (aû) (back, again, other) +‎ τόν (tón) (the) and related to Phrygian αυτος (autos), the existence of alternatives suggesting there may have been a common innovation.  Phagia was from the Ancient Greek -φαγία (-phagía) (and related to -φαγος (-phagos) (eater)), the suffix corresponding to φαγεῖν (phageîn) (to eat), the infinitive of ἔφαγον (éphagon) (I eat), which serves as aorist (A verb paradigm found in certain languages, usually an unmarked form or one that expresses the perfective or aorist aspect) for the defective verb ἐσθίω (esthíō) (I eat).  The alternative spelling is autophagal and the synonyms (sometimes used in non-specialist contexts) are self-consumption & auto-cannibalism.  Autophagia, autophagophore, autophagosome & autophagy are nouns, autophagically is an adverb, autophagocytotic is an adjective and autophagic is an adjective (and a non-standard noun); the noun plural is autophagies.

In cytology (in biology, the study of cells), autophagy is one aspect of evolutionary development, a self-preservation and life-extending mechanism in which damaged or dysfunctional parts of a cell are removed and used for cellular repair.  Internally, it’s thus beneficial, the removal or recycling of debris both efficient and (by this stage of evolutionary development) essential, most obviously because it removes toxins and “effectively “creates” younger cells from the old; it can thus be thought an anti-aging mechanism.  It something which has also interested cancer researchers because all cancers (as the word and the parameters of the disease(s) are defined) start from some sort of cell-defect and the speculation is it might be possible to in some way adapt the autophagic process, re-purposing it to identify and remove suspect cells.

In psychiatry, autophagia refers to the act of eating oneself which is sometimes described as self-consumption or the even more evocative auto-cannibalism.  Perhaps surprisingly, the behavior is not explicitly mentioned in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) which of course means there are no published diagnostic criteria nor recommendations for treatments.  The DSM’s editors note there are a number of reasons why a specific behavior may not be included in the manual notably (1) the lack of substantial empirical evidence or research, (2) the rarity of cases and (3) the material to hand being unsuitable (in terms of volume or quality) for the development of practical tools for clinicians to diagnose and treat a disorders.

It would be flippant to suggest autophagia might have been included when the revisions in the fifth edition of the DSM (DSM-5 (2013)) included a more systematic approach taken to eating disorders and as well as variable definitional criteria being defined for the range of behaviours within that general rubric, just about every other form of “unusual” consumption was listed including sharp objects (acuphagia), purified starch (amylophagia), burnt matches (cautopyreiophagia), dust (coniophagia), feces (coprophagia), sick (emetophagia), raw potatoes (geomelophagia), soil, clay or chalk (geophagia), glass (hyalophagia), stones (lithophagia), metal (metallophagia), musus (mucophagia), ice (pagophagia), lead (plumbophagia), hair, wool, and other fibres (trichophagia), urine (urophagia), blood (hematophagia (sometimes called vampirism)) and wood or derivates such as paper & cardboard (xylophagia).  The DSM-5 also codified the criteria for behaviour to be classified pica (a disorder characterized by craving and appetite for non-edible substances, such as ice, clay, chalk, dirt, or sand and named for the jay or magpie (pīca in Latin), based on the idea the birds will eat almost anything): they must (1) last beyond one (1) month beyond an age in infancy when eating such objects is not unusual, (2) not be culturally sanctioned practice and (3), in quantity or consequence, be of sufficient severity to demand clinical intervention.  However, pica encompassed only “non-nutritive substances” which of course one’s own body parts are not.

Finger food: Severed fingers are a popular menu item for Halloween parties; kids think they're great.  For those who like detail, those emulating nail polish seem to be following Dior shades 742 (top right) and 999 (bottom right). 

In the profession, autophagia seems to be regarded not as a progression from those who eat their fingernails or hair but something with more in common with the cutters.  Cutters are the best known example of self-harmers, the diagnosis of which is described in DSM as non-suicidal self-injury (NSSI).  NSSI is defined as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned; it includes behaviors such as cutting, burning, biting and scratching skin.  Behaviorally, it’s highly clustered with instances especially prevalent during adolescence and the majority of cases being female although there is some evidence the instances among males may be under-reported.  It’s a behavior which has long interested and perplexed the profession because as something which involves deliberate and intentional injury to body tissue in the absence of suicidal intent (1) it runs counter to the fundamental human instinct to avoid injury and (2) as defined the injuries are never sufficiently serious to risk death, a well-understood reason for self-harm.  Historically, such behaviors tended to be viewed as self-mutilation and were thought a form of attenuated suicide but in recent decades more attention has been devoted to the syndrome, beginning in the 1980s at a time when self-harm was regarded as a symptom of borderline personality disorder (BPD) (personality disorders first entered DSM when DSM-III was published in 1980), distinguished by suicidal behavior, gestures, threats or acts of self-mutilation.  Clinicians however advanced the argument the condition should be thought a separate syndrome (deliberate self-harm syndrome (DSHS)), based on case studies which identified (1) a patient’s inability to resist the impulse to injure themselves, (2) a raised sense of tension prior to the act and (3) an experience of release or at least partial relief after the act.  That a small number of patients were noted as repeatedly self-harming was noted and it was suggested that a diagnosis called repetitive self-mutilation syndrome (RSMS) should be added to the DSM.  Important points associated with RSMS were (1) an absence of conscious suicidal intent, (2) the patient’s perpetually negative affective/cognitive which was (temporarily) relieved only after an act of self-harm and (3) a preoccupation with and repetitiveness of the behavior.  Accordingly, NSSI Disorder was added to the DSM-5 (2013) and noted as a condition in need of further study.

However, although there would seem some relationship to cutting, it’s obviously a different behavior to eat one’s body parts and the feeling seems to be that autophagia involves a quest for pain and that suggests some overlap with other conditions and it certainly belongs in the sub category of self-injurious behavior (SIB).  The literature is said to be sparse and the analysis seems not to have been extensive but the behavior has been noted in those diagnosed with a variety of conditions including personality disorders, anxiety disorders, obsessive compulsive disorder, schizophrenia and bipolar disorder.  The last two have been of particular interest because the act of biting off and eating some body part (most typically fingers) has been associated with the experience of hallucinations and patients have been recorded as saying the pain of the injury “makes the voices stop”.  Importantly, autophagia has a threshold and while in some senses can be thought a spectrum condition (in terms of frequency & severity), behaviors such as biting (and even consuming) the loose skin on the lips (morsicatio buccarum) or the ragged edges of skin which manifest after nail biting (onychophagia) are common and few proceed to autophagia and clinicians note neurological reasons may also be involved.    

Lindsay Lohan with bread on the syndicated Rachael Ray Show, April 2019.

Autophagia and related words should not be confused with the adjective artophagous (bread-eating).  The construct was the Artos +‎ -phagous.  Artos was from the Ancient Greek ἄρτος (ártos) (bread), of pre-Greek origin.  Phagous was from the Latin -phagus, from the Ancient Greek -φάγος (-phágos) (eating) from φαγεῖν (phageîn) (to eat).  Apparently, in the writings of the more self-consciously erudite, the word artophagous, which enjoyed some currency in the nineteenth century, was still in occasional use as late as the 1920s but most lexicographers now either ignore it or list it as archaic or obsolete.  It’s an example of a word which has effectively been driven extinct even though the practice it describes (the eating of bread) remains as widespread and popular as ever.  Linguistically, this is not uncommon in English and is analogous with the famous remark by Sheikh Ahmed Zaki Yamani (1930–2021; Saudi Arabian Minister of Petroleum and Mineral Resources 1962-1986): “The Stone Age came to an end not for a lack of stones, and the Oil Age will end, but not for a lack of oil” (the first part of that paraphrased usually as the punchier “the Stone Age did not end because the world ran out of rocks”).

Hatter

Hatter (pronounced hat-er)

(1) A maker or seller of hats.

(2) In Australian slang (1) a person who has become eccentric from living alone in a remote area or (2) a person who lives alone in the bush, as a herder or prospector (now archaic and dating from the 1850s, a synecdoche of “mad as a hatter”).

(3) A student or member of the athletic program at Stetson University in Florida.

(4) In dialectical South Scots, to bother; to get someone worked up (and thus related to the modern “to hassle”).

1350–1400: From the Middle English hatter, the construct being hat + -er.  Hat was from the Middle English hat (head covering), from the Old English hæt (head-covering, hat), from the Proto-Germanic hattuz (hat), from the primitive Indo-European kadh (to guard, cover, care for, protect).  It was cognate with the North Frisian hat (hat), the Danish hat (hat), the Swedish hatt (hat), the Icelandic hattur (hat), the Latin cassis (helmet), the Lithuanian kudas (bird's crest or tuft), the Avestan xaoda (hat), the Persian خود‎ (xud) (helmet) and the Welsh cadw (to provide for, ensure).  The –er suffix was from the Middle English –er & -ere, from the Old English -ere, from the Proto-Germanic -ārijaz, thought usually to have been borrowed from Latin –ārius and reinforced by the synonymous but unrelated Old French –or & -eor (the Anglo-Norman variant was -our), from the Latin -(ā)tor, from the primitive Indo-European -tōr.  The –er suffix was added to verbs to create a person or thing that does an action indicated by the root verb; used to form an agent noun.  If added to a noun it usually denoted an occupation.  Hatter is a noun and the rare hattering & hattered are verbs; the noun plural is hatters.

Lindsay Lohan wearing hats.

The synonyms are hatmaker (or hat-maker) & milliner.  As makers of hats, the difference between a hatter and a milliner is that a milliner is a hat-maker specializing (historically bespoke headpieces) in women's headwear (and works at a millinery shop), while a hatter makes hats for men (and works at a hattery).  In the business of selling hats the distinction blurred, especially in the case of operations which dealt with hats for both men and women.  As a retailer, a hatter could deal either exclusively in hats for men for those for both sexes whereas what was sold by a millinery was (at least intended) only for women.  Milliner was from the Middle English Milener (native of Milan), the construct an irregular form of Milan + -er, the link explained by the northern Italian city being the source of many of the fine garments for women imported into England in the late Medieval age.

Depiction of the mad hatter’s tea party.  Created by Lewis Carroll (1832-1898), The Hatter appears in both Alice's Adventures in Wonderland (1865) and Through the Looking-Glass (1871) and though nowhere in the text does the author make reference to a "mad hatter", that is the popular form and not an unreasonable one, given the madness of both The Hatter and the March Hare is confirmed by the Cheshire Cat.  Lewis Carroll was said to be familiar with the traits of madness and the condition suffered by hatters was well known but some literary historians have speculated The Hatter may have been based on an eccentric shop-keeper.  There’s no documentary evidence to support the claim.

Role model JR Ewing (Larry Hagman, 1931–2012) in Stetson hat.

The use of Hatter (usually in the collective Hatters) to describe students or members of the athletic program at Florida’s Stetson University comes from John B Stetson (1830-1906), otherwise famous as the hatter known for his eponymous hats.  The school was in 1883 founded as the DeLand Academy but was in 1889 renamed Stetson after the Mr Hatter joined the Board of Trustees, the change acknowledging his financial largess.  Thus were born the Hatters and the name (informally) extends to the school’s mascot (who is correctly named John B) which wears a Stetson hat, green bandana, and alligator skin boots.  The mascot is considered equal in status to all other members of the school family.

Lindsay Lohan wearing more hats.

The phrase “mad as a hatter” was first recorded in 1829 and is usually attributed to the correlation noted between those engaged in the profession of hat-making and instances of Korsakoff's syndrome induced by the frequency of them handling mercury-contaminated felt.  The nineteenth century speculation of a link with the Old English ātor (poison) or its descendant the Middle English atter (poison, venom,) lacks evidence has long been discredited.  Korsakoff's syndrome was named after the Russian neuropsychiatrist Sergei Sergeievich Korsakoff (1854-1900 (his work on alcoholic psychosis still influential)) who identified the syndrome which is induced by both exposure to mercury and chronic alcohol use.  A neurological disorder of the central nervous system caused by a deficiency of thiamine, the symptoms include amnesia, deficits in explicit memory, tremors and general confabulation.  The fourteenth century variant “mad as a March hare” alludes to the crazy behavior of hares during rutting season, mistakenly thought to be only in March.

In 1888, a hydrochloride-based process which obviated the need to use mercury when processing felt was patented and in France and the UK, just before the turn of the century, laws were passed banning the use of substance in the making of hats but, as an illustration of the way things have changed, in the US, the risk was ignored by hatters and their employers alike, even trade unions making no attempt to end its use.  Only with the onset of World War II when all available mercury was needed for military production did US hat makers voluntarily agree to adopt the long available alternative process which used hydrogen peroxide.

Cutter

Cutter (pronounced kuht-er)

(1) A person employed to cut something, applied especially to one who cuts fabric for garments.

(2) A machine, tool, knife or other device for cutting.

(3) In nautical use, a single-mast sailing vessel, very similar to a sloop but having its mast set somewhat farther astern, about two-fifths of the way aft measured on the water line.

(4) In nautical use, a ship's boat having double-banked oars and one or two lugsails.

(5) In nautical use, a lightly armed government vessel used to prevent smuggling and enforce the customs regulations (known also as a revenue cutter).

(6) In psychiatry & psychology, a patient who repeatedly inflicts self-injury by cutting their flesh, a behavior traditionally associated with negative emotions.

(7) A person employed as a film editor, the titled derived from when physical film stock was physically cut with blades and re-joined.

(8) A small, light sleigh, usually single-seated and pulled by one horse.

(9) In construction, a brick suitable for cutting and rubbing, traditionally yellow and used for face-work (also called a rubber and now mostly obsolete but still use in restoration work).

(10) In industrial meat production (in the US government’s grading of beef), a lower-quality grade between utility and canner, used mostly in processed products such as hot dog sausages.

(11) In industrial meat production, a pig weighing between 68-82 kg (150-181 lb), from which fillets and larger joints are cut.

(12) In industrial meat production, an animal yielding inferior meat, with little or no external fat and marbling.

(13) In baseball, a variation of the fastball pitch.

(14) In cricket, as "leg cutter", a ball bowled by a fast bowler using finger spin to move the ball from leg to off (when delivered to a right-handed batsman); unrelated to the cut shot ("leg cut" & "off cut") except in the adjectival sense whereby a batsman might be described as “an expert cutter”, “an inept cutter” etc.  The "off cutter" is a delivery which moves in the other direction. 

(15) In dental classification, a foretooth; an incisor.

(16) In UK prison slang, a ten-pence (10p) piece, so named because it is the coin most often sharpened by prison inmates to use as a weapon.

(17) In medical slang, a surgeon (also modified to reflect specialties, neurosurgeons being “head cutters”, thoracic surgeons “chest cutter” etc).

(18) In the slang of criminology, an offender who habitually uses balded weapons to inflict injuries (also known as “slashers”).

(19) In film & television production, a flag, plate or similar instrument for blocking light.

(20) An officer in the exchequer who notes by cutting on the tallies the sums paid (obsolete).

(21) In slang, a disreputable ruffian (obsolete).

(22) As Cutter Expansive Classification (CEC), a library classification system, now obsolete although the core structure remains the basis for the system used by the US Library of Congress.

1375–1425: From the Middle English kittere & cuttere, the construct being cut(t) + -er.  Cut was from the Middle English cutten, kitten, kytten & ketten (to cut) (the Scots form was kut & kit), of North Germanic origin, from the Old Norse kytja & kutta, from the Proto-Germanic kutjaną & kuttaną (to cut), of uncertain origin, though there may be links with the Proto-Germanic kwetwą (meat, flesh) (related to the Old Norse kvett (meat)).  It was akin to the Middle Swedish kotta (to cut or carve with a knife) (the Swedish dialectal forms were kåta & kuta (to cut or chip with a knife)), the Swedish kuta & kytti (a knife), the Norwegian Bokmål kutte (to cut), the Norwegian Nynorsk kutte (to cut), the Icelandic kuta (to cut with a knife), the Old Norse kuti (small knife) and the Norwegian kyttel, kytel & kjutul (pointed slip of wood used to strip bark).  It displaced the native Middle English snithen (from the Old English snīþan) although the German schneiden survives still in some dialects as snithe or snead.  The –er suffix was from the Middle English –er & -ere, from the Old English -ere, from the Proto-Germanic -ārijaz, thought most likely to have been borrowed from the Latin –ārius where, as a suffix, it was used to form adjectives from nouns or numerals.  In English, the –er suffix, when added to a verb, created an agent noun: the person or thing that doing the action indicated by the root verb.   The use in English was reinforced by the synonymous but unrelated Old French –or & -eor (the Anglo-Norman variant -our), from the Latin -ātor & -tor, from the primitive Indo-European -tōr.  When appended to a noun, it created the noun denoting an occupation or describing the person whose occupation is the noun.

A glove cutter at his bench at Omega srl Gloves (the Omega Glove Factory), Rione Sanità district, Naples, Italy.  In American Pastoral (1997), Philip Roth (1933–2018) wrote that no one was able to make gloves as well as “some small factory in Rione Sanità in Naples.”  In the 1980s, most glove production moved from Europe to the Far East and it's believed there are now fewer than a hundred master-certified glove cutters left in the world, the title formalized in seventeenth century France and conferred only after years of mentorship.

Night Suspect, a British Coast Guard Cutter in Pursuit (1958), oil on canvas by Montague Dawson (1890-1973). 

As a surname derived from occupation, Cutter emerged in the late twelfth century, based on the agent noun cutter (“one who cuts something” or “one who shapes or forms by cutting") from the verb cut From the 1630s it came to be used to describe an "instrument or tool for cutting", the use spreading as specialized tools and machines were developed.  In nautical use, beginning in 1792, it was applied to a range of small, single-mast vessels, a borrowing from the earlier use for a “double-banked boat belonging to a ship of war”, noted since 1745 and the rationale is unrecorded but it may have been either because of the similar lines of the hull or the more romantic idea of “cutting through” (moving quickly) the water.  The original ships were the “revenue cutters", lightly-armed government vessels commissioned for the prevention of smuggling and the enforcement of the customs regulations.  The use was therefore for some time restricted to vessels cutter-rigged, but the name has survived to transcend the original specification, almost all revenue ships now powered while the handful of sailed-ships are schooner-rigged.  Modifiers are used to describe various specialized tools used for cutting including biscuit cutter, cigar cutter, bolt cutter, box-cutter, gem cutter, glass cutter, leaf-cutter et al.  The original box cutters, dating from 1871, were those employees with the task of “cutting boxes” while the installed box cutters were pieces of large industrial plant, first noted in 1890; the familiar modern box cutter (hand-held bladed tool for cutting cardboard) first sold in 1944.  A cookie cutter is literally a device used to cut shapes from a sheet of pastry dough but is also used figuratively to describe to things which are un-original or un-imaginative.  Cutter is a noun & adjective; the noun plural is cutters.

Cutters: Non-Suicidal Self-Injury (NSSI)

What cutters do.

Cutters are the best known example of self-harmers, the diagnosis of which is described in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) as non-suicidal self-injury (NSSI).  NSSI is defined as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned; it includes behaviors such as cutting, burning, biting and scratching skin.  Behaviorally, it’s highly clustered with instances especially prevalent during adolescence and the majority of cases being female although there is some evidence the instances among males may be under-reported.  It’s a behavior which has long interested and perplexed the profession because as something which involves deliberate and intentional injury to body tissue in the absence of suicidal intent (1) it runs counter to the fundamental human instinct to avoid injury and (2) as defined the injuries are never sufficiently serious to risk death, a well-understood reason for self-harm.  Historically, such behaviors tended to be viewed as self-mutilation and were thought a form of attenuated suicide but in recent decades more attention has been devoted to the syndrome, beginning in the 1980s at a time when self-harm was regarded as a symptom of borderline personality disorder (BPD) (personality disorders first entered DSM when DSM-III was published in 1980), distinguished by suicidal behavior, gestures, threats or acts of self-mutilation.  Clinicians however advanced the argument the condition should be thought a separate syndrome (deliberate self-harm syndrome (DSHS)), based on case studies which identified (1) a patient’s inability to resist the impulse to injure themselves, (2) a raised sense of tension prior to the act and (3) an experience of release or at least partial relief after the act.  That a small number of patients were noted as repeatedly self-harming was noted and it was suggested that a diagnosis called repetitive self-mutilation syndrome (RSMS) should be added to the DSM.  Important points associated with RSMS were (1) an absence of conscious suicidal intent, (2) the patient’s perpetually negative affective/cognitive which was (temporarily) relieved only after an act of self-harm and (3) a preoccupation with and repetitiveness of the behavior.  Accordingly, NSSI Disorder was added to the DSM-5 (2013) and noted as a condition in need of further study.

KEIBA Side Cutters.

Although interest in the cutters spiked in the 1990s, papers had been published as early as the 1930s and the literature suggests something of a consensus among clinicians it should be regarded a matter of self-mutilation, such acts a form of attenuated suicide.  Accordingly, all non-fatal and deliberate forms of self-injury tended to be viewed as suicide attempts, regardless of whether there was any expressed suicidal intent and it wasn’t until the 1960s that any volume of doubt emerged.  That was significant, not only because self-injury was coming to be understood as something distinct from attempted suicide but that it implied the instance of attempted suicide was significantly overstated, something of interest to many.  This led to the coining of the novel word “parasuicide”, perhaps an indication the profession still preferred to think cutting a sub-set rather than anything distinct.

Cutters' scars, fresh & fading.

For clinicians, NSSI can at the margins be a difficult diagnosis.  To fit the diagnostic criteria in the DSM-5, NSSI must be intentional and deliberate but acts sometimes occurs during dissociative episodes so a judgment needs to be made determining whether an act can be held to be intentional if the patient is detached from reality.  As a definitional matter. there’s also the issue that if the motivation is to “feel something” some degree of intentionality seems at least implied but these examples do illustrate why NSSI among those suffering an episode of dissociation need even more carefully to be assessed before a diagnosis is decided.  There’s also a threshold criterion for the injury suffered, wounds needing to be “moderately intense” to qualify, thus the exclusion of such as lip-biting, scab & skin picking, hair pulling and nail-biting, even if these injuries might demand clinical care in another context (and may well be relevant in assessment measures).  Some extent of a “destruction of body tissue” is thus required and the current DSM-5 definition specifies bleeding or bruising.  However, it’s noted in cases studies that while minor and highly normative behaviors such as lip-biting, skin picking and hair pulling are excluded: (1) When severe they may be indicative of another specific condition such as trichotillomania (hair-pulling disorder) or excoriation (skin-picking disorder) rather than NSSI and (2) repeated and obsessional instances of behavior that might otherwise be considered mild and normative might appropriately be diagnosed as NSSI.

Case Fatality Rates by Suicide Method (8 indicative US states, 1989-1997)

Although the instances of death resulting from cutting are low, it’s clear many patients engage in NSSI behaviors while experiencing thoughts of suicide and while the evidence suggests many report being resigned to death as a consequence of cutting, actual suicidal thoughts and hopes for death are markedly higher in those exhibiting suicidal behaviors.  Intriguingly, it seems some may engage in NSSI as a way to avoid acting on thoughts of suicide; NSSI for these patients serving to regulate and reduce suicidal thoughts and intentions.  So it’s clear that in both thought and behavior, there’s some overlap between NSSI and suicidal thoughts meaning that even if a cutter’s injuries are (medically) minor, the condition should not be thought trivial although, for practical purposes, NSSI and suicidal behaviors need still to be categorized separately.  Cutting is also special in that it is so overt, unlike other forms of self-harm such as alcohol & drug abuse, risky behavior or neglecting to follow a prescribed treatment for a chronic condition.  There does however seem to be a pronounced co-morbidity between NSSI and eating disorders, the obvious link being a patient’s relationship with their body, NSSI being in some sense a compensatory behavior and form of self-punishment.  Data is clearly accumulating but the APA’s editorial committee seem not yet ready to make major structural changes: in the DSM-5-TR (Text Revision, 2022) although codes were included both suicidal behavior and NSSI, Suicidal Behavior Disorder (SBD) and NSSI Disorder remained in the section “Conditions for Further Study”.

US Coast Guard Legend Class National Security Cutter.