We would like to provide our thanks for an insightful piece on the relevance of gift giving in the context of a patient doctor therapeutic relationship. We would like to provide a psychoanalytic account of the various types of generosity, and how this can be a manifestation of psychiatric disorder.
We have encountered gift giving which had irrefutable consequences both on the person’s social but also personal level of functioning. The compulsion to carry out this act is strong, unamenable to reasoning and clearly pathological. We discovered pathological generosity can cause immense difficulty in the life of the sufferer, and to their loved ones. It may also have significant financial and social repercussions. In spite of this, the evidence base concerning pathological generosity is small, and information to guide treatment strategies is nearly non-existent. Our literature search yielded three peer reviewed articles which included one case study.
Generosity is defined as an individual’s capacity to sacrifice their material means in order to benefit others (Orgel S et al, 1968). This is to the extent whereby no profit or gain to one’s social reputation is expected in response (Ferreira-Garcia R et al, 2014). Akhtar (2012) defined 5 subtypes of pathological generosity: unrelenting generosity; begrudging generosity; fluctuating generosity; controlling generosity; beguiling generosity. The first three are described as abnormalities in the ‘intensity, nature and sustenance of generosity’. The last two are described as ‘pseudo-generosity’, because these are not motivated by complete lack of concern for oneself (Akhtar S, 2012).
Unrelenting generosity describes ‘excessive’ giving to others without pause or interruption. The individual concerned is typically not conscious of overstepping limits. The generosity can be such that the individual depletes their resources. Begrudging generosity is characterised by those who give but with reluctance and little enthusiasm (Akhtar S, 2012). Fluctuating generosity describes patterns of alternating generosity and parsimony. In controlling generosity there are conditions attached to gifts, and there can be a sad*stic element to the giving. Beguiling generosity is similar to controlling generosity but the giver can appear sincere while being in reality deceptive.
Pathological Generosity has been associated with a variety of psychiatric conditions. It can be a clinical manifestation of mania. It has also been reported in diseases that affect brain structure and function - including dementias - notably the temporal variant of Fronto-temporal Dementia. It is also associated with head injury, neuro-syphilis, and Parkinson’s disease treated with Dopaminergic Drugs (Ferreira-Garcia et al, 2014).
Pathological generosity can also be secondary to an enduring, pervasive personality disorder. A subject with underlying narcissistic personality traits may give excessively as part of their grandiose ideals or with the expectation that they would gain societal admiration. Patients with dependent personality disorders can find it difficult to make the simplest of demands from their perceived carer and show evidence of subordination. This is due to the apprehension of being rejected or abandoned by their care giver. Both these described behaviours satisfy the definition of generosity and in particular the ‘beguiling’ subtype.
Treatment should be approached in a multidisciplinary manner, initiated by a careful history and mental state examination. It should be part of a comprehensive treatment package for the underlying condition. The financial and social consequences of pathological generosity on patients and their families can be immense. Furthermore, the true prevalence of pathological gift-giving is not known, as systematic studies are lacking. Given the high prevalence of head injury and this being a possible aetiological factor, it is quite possible that there are a significant number of undetected cases, in which the person at present does not have access to treatment. Further awareness and research in this area would be warranted.
References
1.Akhtar, Salman. (2012) Normal and pathological generosity, Psychoanal Rev 99, 645-676.
2.Ferreira-Garcia, Rafael & Fontenelle, Leonardo & Moll, Jorge & Oliveira-Souza, Ricardo. (2014) Pathological generosity: an atypical impulse control disorder after a left subcortical stroke, Neurocase 20, 496-500.
3.Orgel, Shelley & Shengold, Leonard. (1968) The fatal gifts of Medea, The International Journal of Psycho-Analysis 49, 379-383.
