A MALADY OF REPRESENTATIONS
Dr. Russell Meares
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A MALADY OF REPRESENTATIONS
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There is an important category of 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 manifest 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. Here are some examples:
- A young woman who had been in therapy for about a year telephoned her therapist some time after a session, which was an unusual thing for her to do, and reported that as she was preparing for a shower, she noticed a number of bruises behind her knees, which bewildered her. The therapist saw her the next day and found several linear but incomplete lesions behind the patient’s knees. This incident might perhaps have been anticipated since, several years before entering therapy, the patient had been investigated by a physician for large linear bruises that occurred intermittently on her arms and legs. The physician was baffled by these bruises and could find no cause for them. They became a focus of therapy. One day the patient recalled being made to face the wall and, while she was caned, to keep her legs perfectly straight. “Phew!” she said. “She used to be cruel. Nowadays you would call it child abuse.” It was following this session that the bruises appeared spontaneously behind the patient’s knees.
- A middle-aged woman had an intermittent sensation of a male hand under her chin, grasping it between thumb on one side of her chin and fingers on the other. It turned out that this symptom had its origin in her being forced to commit fellatio regularly with her father as a preadolescent.
- A woman in her 30s had the strange sensation, from time to time, of something like a silken cord moving obliquely across her face in a wavering line. This sensation occurred particularly when she was anxious. Eventually a link was discovered that related her facial sensation to a car accident some years before. In the moment before impact, she could see that the accident was about to happen and at that instant felt the terror of knowing she was about to die. She was not, however, seriously injured, but, as she lay on the roadside, blood from a scalp wound trickled obliquely across her face.
- A woman in her 40s who had been sexually attacked by two men would feel, intermittently, the skin of her forearms twisting laterally. This was a “body memory” of being held down by the arms by one man while the other raped her.
- The skin on the face and hands of a woman in her early 30s would, from time to time during a therapeutic session, become blue and mottled, as if from cold. When her therapist inquired about the skin changes, the patient had no explanation for them. It later emerged, however, that during childhood she was punished by being locked in a closet that was totally dark and in a part of the house that was freezing cold. This experience was frightening.
In each of these examples, the symptom represents an element of traumatic memory that was initially unconscious. Janet called hysteria an “ensemble of maladies of representation” (1901, p. 488). Breuer and Freud concurred, noting that “the hysteric suffers mostly from reminiscences” (1895, p. 4). Until recent years, there have been few reports of phenomena such as these. Presumably they were ignored as medically meaningless or discounted as mere fabrications. In the years before World War I, however, they formed part of the descriptive background of the complex condition then called hysteria. The possibility that at least some of these phenomena reflect changes in the blood supply to the skin is suggested by the observations of Janet. He found, for example, that anesthesia of the arm is associated with markedly reduced blood flow (Janet, 1901, p.11). He also described the remarkable case of a young woman, observed over a period of 10 years, who had a persistent pulse of 100 and a temperature about 2 degrees Fahrenheit above the normal, suggesting a disturbance of autonomic regulation of body temperature (Janet, 1925, pp. 1050–1051). Her symptoms could not be explained in terms of illnesses such as thyrotoxicosis. Her abnormal temperature did not inconvenience her. She complained, however, of fever when she had a slight attack of influenza. Janet noted that the “disorders of the peripheral circulation taking the form of passive dilation of the blood vessels or of vasomotor spasm” (1925, p. 1051) were not uncommon. “A great many of these patients are continually becoming affected with redness or pallor of the skin of various regions” (p. 1051). In several of his patients, “patches on the skin, at first red and hot, and then pale and very cold, [are] apt to become blue on the following day, and that for a long time in these areas a bruise is left” (p. 1052). In one case the bruising was associated with “actual ecchymoses” (p. 1051).
Are These Dermal Representations Dissociative?
The sensations and/or marks on the skin representing traumatic memory in some patients with BPD are like analogues of the PTSD flashback and nightmare. The dermal imprint might be conceived as another form of what Lenore Terr (1988) called a “burning in” of the trauma (p. 105). The visual representation, which “is often the repetition of the actual experience without transformation of any kind,” as W. H. R. Rivers remarked (1922, as cited by McDougall, 1926, p. 138), is larger and more coherent than the dermal one. The latter is also qualitatively different from PTSD in that the individual is typically unaware of the origin of the skin phenomena. Are they, then, dissociative?
In terms of the hypothesis being put forward at the beginning of the chapter about the origins of this category of BPD phenomena, the imprints on the skin representing trauma are dissociative. They can be understood in terms of Rivers’s use of the great neurologist Sir Henry Head’s (1918) definition of dissociation. Head considered it a process “whereby one set of nervous functions are separated from others with which they are normally
associated so that they become capable of independent study” (Rivers, 1922, p. 71). Rivers considered “the word ‘dissociation’ [to be] peculiarly appropriate to the psychological process” (p. 72).
Janet’s description of cases involving dermal representation and trauma suggest a dissociative basis. The famous case of Marie provides an example (Janet, 1901, pp. 282–285). Marie was a young girl from the country who had been hospitalized because she was judged insane and incurable. Janet discovered a number of traumatic incidents in her past. A principal one involved the onset of menstruation at the age of 13. For some reason, “she took it into her head that there was some shame connected with the affair, and sought some means whereby to stop the flow as soon as possible. In the course of some twenty hours she went out and secretly plunged into a big tub of cold water. She succeeded completely, the courses stopped suddenly, and notwithstanding the severe chill that followed, she was able to reach home” (pp. 283–284). This episode was followed by an illness in which she was delirious for several days.
Her periods stopped for 5 years but when they returned, she suffered a crisis at each menstruation. Twenty hours after the onset, the flow stopped suddenly and a severe chill shook her whole body. Then followed a dissociative delirium with florid symptomatology, including hallucinatory representations from other traumata. The episode, which lasted about 48 hours, “ended with several blood vomitings.” She remembered nothing of the experience. Janet remarked that the scene of the cold bath “takes place below the surface of consciousness” (1901, p. 284).
Although accounts as exotic as that of Marie are rare, it is becoming evident that much lesser forms of the phenomenon are not uncommon. This evidence suggests that they may be an aspect of dissociation. For example, Madhulika and Adilya Gupta (Gupta & Gupta, 2006) asked 360 people—44 psychiatric outpatients and 314 nonclinical participants—to complete both the Dissociative Experiences Scale (DES) and an extensive checklist of cutaneous symptoms. They found that the symptom score correlated with the DES total score. They then considered those 17 people whose DES scores were considered pathological and found that their mean score on the cutaneous symptoms scale, 360, was much higher than the mean score of the remaining participants, which was 70. Pain, itching, and numbness were the best predictors of the DES score.
Although numbness, and to some extent pain, have long been associated with the phenomenon of dissociation, itching has not. Pruritic states, however, may represent “body memories” of traumatic memory. One of our own cases supported this possibility. The patient, a woman of late middle-age, presented to a physician with a 15-month history of recurrent episodes of formication and pruritus, particularly in the pubic area. This formication, described as a creepy feeling that bugs were crawling under her skin, was accompanied by feelings of being “unclean” and unfit to be around others. A provisional diagnosis was made of connective tissue disorder. She was intensively reviewed by an immunologist, who found no abnormalities. Since she was also depressed, she was referred to our clinic. It emerged that her symptoms had begun soon after an incident in which she felt as if she had been physically assaulted in the stairwell of the apartment house in which she lived. During this “assault,” an obese male neighbor thrust his large abdomen into her abdomen in an intimidating way, as if he were trying to bump her out of the way. She was extremely distressed by this incident. Her symptoms remitted during therapy (Meares & Jones, 2009). A traumatic precursor to the bumping incident was not revealed, nor was it sought.
Two remarkable case histories from R. L. Moody, reported in The Lancet in 1946 and 1948, suggest an association between the state of dissociation and the representation of trauma by vascular changes in the skin.
In the first of these cases a man of 35 was admitted to a hospital in 1944 “because of somnambulism accompanied by aggressive behaviour” (Moody, 1946, p. 934 ). He was an Army man, but no account was given of his military service. In a previous hospital admission in 1935 for a minor septic condition, he had been “retained five months because of somnambulism” (p. 935). During this admission various restraints were imposed upon him to prevent his nocturnal wanderings. “On one such occasion his hands had been tied behind his back during sleep, as a precautionary measure. Waking in a dissociated state he had struggled unsuccessfully to free himself. He had then managed to evade his bodyguard and had escaped into the surrounding countryside from which he had returned a few hours later” (p. 935).
One night, during a later admission in 1944, “the patient was observed to be tossing and turning violently in his bed. He was holding his hands behind his back and appeared to be trying to free them from some imaginary constriction. After carrying on in this way for about an hour, he got up, and with his hands still in the same position, crept stealthily into the hospital grounds” (Moody, 1946, p. 935). He came back after 20 minutes in an apparently normal state of mind.
Two nights later Dr. Moody abreacted the patient by means of intravenous narcosis:
He slept for a few minutes and then began reciting poetry (this was a common prelude to his somnambulism). Then minutes later he began to toss and turn on the couch, with his hands behind his back. As he appeared to be in a completely dissociated state, I turned the light full on him. I watched him writhing violently for at least three quarters of an hour. After a few minutes weals appeared on both forearms; gradually these became indented; and finally some fresh petechial haemorrhages appeared along their course. (Moody, 1946, p. 935)
A photograph of these indentations was included in Moody’s Lancet paper.
In this article, Moody briefly mentioned three other cases of abreaction of traumata being followed by bodily “representations” of an aspect of the trauma. Swelling at points on a man’s body recurred where he had been injured by a flying bomb; a seaman who had been immersed in very cold water for a long time showed localized ischemia of the extremities; a woman injured in a riding accident at the age of 10 showed petechial hemorrhages along the tenth rib, which had been fractured in the accident.
In each of these cases, the history given was insufficient to infer a BPD diagnosis. However, the background of the case presented in Moody’s 1948 article was very like that told by a person who would now be given the borderline diagnosis. The patient was a married woman in her late 30s, who had had “an extremely unhappy childhood in which a sadistic father had played a prominent part” (p. 964). During Dr. Moody’s abreactions of her traumata, “swelling, bruising and bleeding were observed on at least thirty occasions” (p. 964). They included the following: (1) “The morning after abreacting an incident in which she had been thrashed with a cutting whip at 8 years, three large bruises of appropriate shape appeared on her left buttock” (p. 964). (2) A few minutes after abreacting an incident in which she had
cut herself rushing through a window, long red streaks appeared down each leg. The patient reported that these bled during the night. (3) Bruising after an abreaction had a “curious sharply defined pattern” resembling an elaborately carved stick her father had used to beat her.
None of the symptoms observed by Dr. Moody or by my colleagues and myself could have been explained by trickery or as factitious. Certain of the phenomena resembled the famous story of Padre Pio, whose body at times bore the signs of the stigmata, the wounds that Christ suffered on his hands, feet, and side at the crucifixion. In the 1920s the Vatican suspected that the oozing blood observed at the sites of the stigmata was factitious, and he was banned from celebrating Mass in public for over a decade. However, no evidence was ever found to suggest that the bleeding was self-inflicted and that he was a fraud. Padre Pio was extremely popular. Hundred of thousands of people converged on the Vatican for the occasion of his canonization by Pope John Paul II in 2002.
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