Libyan Journal of Medical Sciences

: 2020  |  Volume : 4  |  Issue : 3  |  Page : 137--139

Self-induced anemia secondary to overvalued belief on cupping: A Case report and review of the literature

Abdulhak A Sadalla1, Asmaa Gh Hussein2, Mohammed A Amer3,  
1 Department of Medicine, Al-Emadi Hospital, Doha, Qatar
2 Department of Psychiatry, Hawler Medical University and Teaching Hospital, Erbil, Iraq
3 School of Medicine, University of Jordan, Amman, Jordan

Correspondence Address:
Dr. Abdulhak A Sadalla
Al-Emadi Hospital, Doha


Bloodletting as a treatment for various diseases is an ancient belief; nowadays, it is practiced in many communities, especially in Asia and the Middle East. Among others, cupping is one form of bloodletting procedure. We are presenting a patient with overvalued belief (idea), he relied on cupping as a therapy to treat his headache. For many years, cupping was done for him every few months, then he tried doing it himself, more frequently. Thereafter; cupping sessions dominated his life in a way that he used to do it every few days and whenever he felt a headache. Over the years, the patient sustained severe anemia, although it was self-induced; however, it was not factitious as his intention was to cure himself rather than inducing self-harm. Management was a challenge as it was difficult to convince him to stop this practice and to consult psychiatrist.

How to cite this article:
Sadalla AA, Hussein AG, Amer MA. Self-induced anemia secondary to overvalued belief on cupping: A Case report and review of the literature.Libyan J Med Sci 2020;4:137-139

How to cite this URL:
Sadalla AA, Hussein AG, Amer MA. Self-induced anemia secondary to overvalued belief on cupping: A Case report and review of the literature. Libyan J Med Sci [serial online] 2020 [cited 2023 Mar 28 ];4:137-139
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Full Text


Bloodletting is one of the oldest medical interventions. It was done in various ways for thousands of years: phlebotomy, cupping, and the use of leeches. The belief that bloodletting had therapeutic value was widespread since the fourth century B. C. Hippocrates (460–370 BC) practiced phlebotomy. Herophilus (335–280 BC) is regarded as the founder of bloodletting as a treatment.[1],[2] Bloodletting behavior is also found in religious texts: “Hijama” is the name used in Islamic countries, which is thought to heal a number of diseases, including mental illness. Christian writings mentioned the therapeutic role of bloodletting, advising doing it on the “All Saints Day.”[1]

Cupping therapy is an alternative medical procedure, which has been widely performed, especially in Asian countries, to relieve pain and to manage other conditions, usually by nonhealthcare professionals. However, many complications had been identified, such as infection, iron deficiency anemia, hemorrhagic bullae, scars, and skin pigmentation.[3]

Overvalued belief (idea) is a psychiatric disorder characterized by solitary abnormal belief, which is neither delusional nor obsessional in nature. It preoccupies and dominates the sufferer's life and carries a bad prognosis.[4],[5],[6] Herein, we report a case with an overvalued belief (idea). The patient relied on cupping as a therapy to treat his headache. Over years of using it, he sustained severe anemia.

 Case Report

A 54-year-old retired male presented with fatigability and exercise intolerance for 5 months. In the past, he was diagnosed with a minor stroke 9 years ago, and then he had recurrent attacks of headache, each lasted for many hours with poor response to painkillers. The patient gradually developed a belief that to get rid of his headache, he should discard some blood: “the spoiled blood.” Accordingly, he used to visit a traditional therapist for cupping. For many years, it was done for him every few months with the extraction of about 50 ml of blood from his back. Thereafter; cupping became his main concern; he used to ask his wife to do it for him every week; after a while, she refused to do it anymore, but he did not stop here; he tried doing it himself on accessible body parts. After months, he reached a limit of doing self-cupping every week, and whenever he felt a headache, stating to his family that it is the right way to fight his illness.

On physical examination, the patient was severely anemic with a crusty skin lesion in the forehead and a pigmented scar of repeated cupping in the right temple [Figure 1] and [Figure 2], pulse rate: 98 beat per minute, blood pressure 105/68 mmHg with an apical systolic murmur, otherwise cardiorespiratory and nervous systems were within normal. The patient appeared anxious; his speech was coherent and relevant. He had an overvalued belief about the efficacy of cupping in managing his illness and he was suspicious about the outcome of medical management. There was no delusion, obsessional or suicidal thoughts, and there was no other abnormal belief. The cognitive function, including insight, appeared intact.{Figure 1}{Figure 2}

Hemoglobin level was 4.1 g/L (13–17 g/dl), blood smear showed marked anisopoikylocytosis, hypochromic microcytic red blood cells, and the serum ferritin was 6.5 ng/ml (10–160 ng/ml). Renal function, liver function tests, and other biochemistry were within the normal limits. A diagnosis of overvalued belief on cupping was concluded, it resulted into severe self-induced anemia, the patient was advised to stop this practice, iron preparation was prescribed but the patient refused formal psychiatric consultation.


The patient showed gradual development of an abnormal belief. It started with reliance on cupping as a healing mean for his headache then it became his main concern and preoccupation. Repeated cupping has induced severe and chronic anemia. Unlike delusion which tends to appear suddenly, coexists with hallucination and more than one delusion are usually found at a time. Our patient's belief had been evolved over the years, no coexisting hallucination and it was his only abnormal belief. In addition, our patient appeared concerned with other's opinion which is unusual among delusion patients.[4],[5],[6]

Our patient's goal was to treat himself, but he was unaware of inflicting self-harm. Although his anemia is self-induced; however, it should be differentiated from factitious anemia. In factitious disorder the sufferer deliberately pretends symptoms and fabricates signs, assuming the “patient role” to achieve emotional gratification without any obvious external gain.[7],[8]

Repeated cupping among other bloodletting practices carries potential complications, even death was reported, while others did not find a single cupping session as harmful.[9],[10],[11],[12] Management of overvalued belief is a challenge as symptoms are gradual and the patient is refractory to medical advice and therapy.[5],[6]


Self-induced illness can result from misconception and overvalued belief.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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