A MALADY OF REPRESENTATIONS

A MALADY OF REPRESENTATIONS

Dr. Russell Meares

There is an important category of borderline personality disorder (BPD) phenomena that is very often overlooked but that may relate to the core of the disorder. It is overlooked, first, because the patient does not report it and, second, because, if reported, it seems incidental to the main clinical picture and also inexplicable. It appears as an almost literal imprint in the body, particularly the skin, of a fragment of traumatic experience. The symptoms of this phenomenon can be understood in terms of a disconnection theory of BPD. They seem to reflect autonomic nervous activity that is independent of, and uncoordinated with, higher systems, particularly the prefrontal cortex. Rule et al. (2002) have proposed that the orbitofrontal cortex is central to the top-down regulation of subcortical functioning of structures such as the autonomic system, the hypothalamus, and the amygdala, all involved in the induction, activation, encoding, and elicitation of emotion. The phenomenon considered in this chapter appears to reflect a loss of this regulation and to mani- fest a “dissociation” of the autonomic nervous system activity from prefrontal regulation, particularly as it controls the dermal vascular bed. Quite intricate patterns of skin sensation and even skin markings arise in some traumatized patients with BPD, like sensory “maps” of parts of the trauma.

 

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