Body Disownership in Complex Posttraumatic Stress Disorder

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BODY

DISOWNERSHIP

IN COMPLEX POSTTRAUMATIC

STRESS DISORDER

Yochai Ataria Body Disownership in Complex Posttraumatic Stress Disorder Yochai Ataria Body Disownership in Complex Posttraumatic Stress Disorder Yochai Ataria Tel-Hai College Upper Galilee, Israel

ISBN 978-1-349-95365-3 ISBN 978-1-349-95366-0 (eBook) https://doi.org/10.1057/978-1-349-95366-0

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This Palgrave Macmillan imprint is published by the registered company Nature America, Inc. part of Springer Nature The registered company address is: 1 New York Plaza, New York, NY 10004, U.S.A. Dedicated with great love to Adi, Asaf, Ori and Shir For making life worth living. The publication of this book coincides with the fortieth anniversary of Jean Améry’s suicide and is dedicated to him and to all those like him who were sentenced to life but chose death instead. Foreword

What happens at the most negative extremes of torture and trauma? What happens to our bodies and to our selves? Yochai Ataria, in Body- Disownership in Complex Posttraumatic Stress Disorder, provides analyses of a variety of body-related orders and disorders, with special focus on trauma and the effects of torture. He works frst hand with those who have suffered such extremes, and who witness to that frst-person experience they lived through, and continue to live through. His analyses are fully informed by phenomenology, especially the work of Merleau-Ponty, as well as by recent science and research in psychiatry. The phenomenological difference between the body-as-subject or lived-body (Leib) and the body-as-object (Körper) is a basic distinction informing Ataria’s analysis. He also builds on a number of other distinctions drawn from both phenomenology and neuroscience—for example, body-schema versus body-image, and sense of agency versus sense of ownership. From a particular perspective, these distinctions line up in parallel, where on one side there are connections between body-as-subject, body-schema, and sense of agency, and on the other side connections between body-as-object, body-image, and sense of ownership. With respect to these relations, however, Ataria uses the mathematical symbol “ ,” which means more or less equal or approximately equal. This ≈ is an important sign of qualifcation. These concepts are not equivalent. Indeed, their lack of equivalence and their varying degrees of ambiguity, as well as the cross—and sometimes close—connections between the two sets of parallel concepts, provide them with their explanatory power.

ix x Foreword

The analyses provided by Ataria are thus nuanced and complex in signifcant ways. Take for example the distinction between sense of agency and sense of ownership. Each is complex and a matter of degree. Moreover, in typical everyday experience, these two pre-refective aspects are tightly integrated. It’s diffcult to pull them apart, either phenomenologically or neurologically. In terms of neuroscience, both experiences depend upon sensory integration processes (some of which are likely correlated with activation in the insula). They involve vestibular sensations, proprioception, kinaesthesis, vision, and perhaps other sensory inputs. The sense of agency also requires the integration of efferent processes involving motor control. In the case of involuntary movement, one starts to see how sense of agency and sense of ownership can be distinguished, since in the case of involuntary movement it is still my body that is moving, but I am not the agent of that movement (in such cases, no efferent processes are involved in the initiation of the movement). This is the simplest case that provides a dissociation. But in most cases of voluntary action or involuntary movement, the situation is much more complicated, and Ataria explores a number of other complex and in some cases paradoxical dissociations. The enactivist conception of action-oriented perception—the idea that we perceive things in terms of what we can do with them—is central to Ataria’s argument. Trauma leads to breakdowns in this pragmatic know-how that typically informs our perceptions and actions. These are breakdowns in the relational integration of body and world and therefore breakdowns in the affordance structures of our everyday lives. Problems are not confned to just this kind of sensory-motor know-how; however, the problems are equally of an affective nature. Emotion and mood play major roles in constituting our way of being-in-the-world. Across perceptual, motor, and affective dimensions, we fnd deep transformations in the extremes of the kind of trauma associated with war, violence, rape, torture, and even the slow effects of solitary confnement. In connection with traumatic effects, one might not think of the unusual experiences of autoscopy, heautoscopy, and out-of-body-experiences, and specifcally experiences that have been replicated experimentally both by direct neuronal stimulation and by the fascinating use of virtual reality (this is the important work of Olaf Blanke and colleagues). But this is just what Ataria does. He shows the resemblances of these phenomena, which are seemingly like the effects of quantum indeterminacy, but on the level of bodily experience. Can I really be at two places at one ForewoRD xi time, and can that really offer a kind of self-protection; or do they signal a dissolution of self? These are some of the most paradoxical and perplex- ing experiences possible. Ataria considers dehumanization in the form not only of being reduced to a merely animal status, for even animals live through their bodily existence in a way that is not too distant from the human; but a dehumanization in the form of being reduced to a mere thing. The inhuman conditions in Nazi concentration camps, for example, resulted in the development of a defensive sense of disownership toward the entire body. The body, in such cases, is reduced to a pure object. At the extreme, this body-as-object, which had been the subject’s own body, is experienced as belonging to the torturers and comes to be identifed as a tool to infict suffering and pain on the subject himself. In this situation, robbed of cognitive resources, the subject may have no other alternative than to treat his body as an enemy, and accordingly, retreat, or disinvest from the body. This kind of somatic apathy is an indifference involving a loss of distinction between the self and the nonself. It too often leads to suicidal inclinations, even after liberation from the camp. Ataria thus explores, the mind’s limit, to use a phrase from Jean Amery. He follows a route that leads the mind to a dead end in the body, taken as pure object. The body, which is not other than the mind, comes to be so, and so alien, through torture and specifc kinds of trauma. Such experiences have the potential to destroy all aspects of self: the physical, the experiential, the cognitive and narratival, and the profoundly inter- subjective. The question then is: What is left? What resources might the subject use to recover? That’s a challenge that many victims and survivors face, and it is well worth trying to understand.

Memphis, USA Shaun Gallagher Acknowledgements

In 2014, Shaun Gallagher invited me to attend a conference in Memphis titled “Solitary Confnement: Phenomenology, Psychology, and Ethics.” At this conference, I raised the ideas put forward in this book for the frst time. Not only do I want to thank Shaun for inviting me to this conference. I am also grateful for his continuous support during my doctoral studies, for our joint writing, and for our ongoing dialogue. I cannot imagine this book being written without his major contribution. I began writing this book during my doctoral studies, and it is based in part on research I conducted while working on my thesis. I wish to thank Yemima Ben-Menahem and Yuval Neria, my two doctoral advisors. I could not have asked for better advisors. Special thanks to Koji Yamashiro, Shogo Tanaka, and Frederique de Vignemont, who read the book in depth. I could not have reached the point where I am today without their challenging and important comments. I also want to thank Peter Brugger, Eli Somer, Roy Salomon, Iftah Biran, Mooli Lahad, and Eran Dorfman, who read some of the chapters and made a major contribution. I engaged in ongoing dialogue about some of the ideas in the book with colleagues—Omer Horovitz, Ayelet Shavit, Eli Pitcovski, Thomas Fuchs, Amos Goldberg, Mel Slater, and Amos Arieli—and I am grateful to them for their patience and understanding. I claim full responsibility for any errors that remain in the book. This book underwent many changes as a result of lectures I gave over the past three years, and I thank all those who attended my seminars at

xiii xiv Acknowledgements the following institutions: Berlin School of Mind and Brain, Humboldt Universität; Tel Aviv Sourasky Medical Center—Psychiatric Hospital; Department of History, Philosophy and Judaic Studies, The Open University of Israel; Interdisciplinary Center Herzliya; Virtual-Reality & NeuroCognition Lab, Faculty of Education in Science and Technology, Technion; The Bob Shapell School of Social Work, Tel Aviv University; The Cohn Institute, Tel Aviv University; Vision and Human Brain Lab, Department of Neurobiology, Weizmann Institute of Science; The École normale supérieure (ENS), Archives Husserl; The Hebrew University of Jerusalem; University of Haifa; The University of Memphis; Tokai University; Psychiatric Department, University of Heidelberg. The contribution of the various comments made during these seminars and con- ferences cannot be exaggerated. I would also like to thank Rebecca Wolpe and Donna Bossin, who, respectively, edited and translated this book. Finally, I extend my heartfelt thanks to Rachel Krause Daniel, Senior Commissioning Editor for Scholarly and Reference Books at Palgrave Macmillan, for believing in me and in my work. Her support was of crucial importance in getting the book published. I would like also to thank Kyra Saniewski for her close and ongoing support during the writing of the book. * I am grateful to Tel-Hai College, without whose help and support this book would not have been published. Contents

1 Introduction 1 1.1 When the Body Is the Enemy—Améry’s Basic Intuition 1 1.2 Disownership 2 1.3 Trauma—The Collapse of the Knowing-How Structure 5 1.4 Complex Posttraumatic Stress Disorder 8 1.5 Outline of the Book 9 References 11

2 The Twofold Structure of Human Beings 13 2.1 The Twofold Structure of the Human Body 13 2.2 Body-Schema and Body-Image 17 2.2.1 Theory of Body-Schema—Theory of Perception 17 2.2.2 Body-Schema Versus Body-Image: Double Dissociation 19 2.2.3 Nothing Is Within Our Reach 22 2.3 What Not-Belonging Feels Like 23 References 26

3 Ownership 29 3.1 Ownership Versus Sense of Body-Ownership (SBO) 29 3.2 SBO—Manipulations 30 3.2.1 The Rubber Hand Illusion 31 3.2.2 Prosthetic Limbs 31

xv xvi Contents

3.3 Lack of Sense of Ownership Toward the Entire Body 36 3.3.1 Autoscopic Phenomena 37 3.3.2 Minimal Phenomenal Selfhood (MPS) 41 3.3.3 Total Lack of Sense of Ownership Toward the Entire Body 44 3.4 SBO—Main Insights 49 References 49

4 When Ownership and Agency Collide: The Phenomenology of Limb-Disownership 53 4.1 Sense of Agency 53 4.2 Ownership vs. Agency: Double Dissociation 55 4.3 Towards a Theory of Limb-Disownership 58 4.3.1 Somatoparaphrenia 59 4.3.2 Body Integrity Identity Disorder (BIID) 66 4.3.3 Some Insights Concerning Limb-Disownership 74 References 75

5 The Complex Relations Between SA and SBO During Trauma and the Development of Body-Disownership 81 5.1 Dissociation—A Defense Mechanism Activated During Trauma 81 5.2 Weakening of the SBO During Trauma 82 5.3 Loss of SA 85 5.4 The Relations Between SBO and SA During Trauma 87 5.5 The Development of Body-Disownership 90 5.5.1 Body-Disownership—What Does It Feel Like 91 References 97

6 Self-Injuring Behavior 101 6.1 Self-Injuring Behavior: A Brief Introduction 101 6.2 Self-Injuring Behavior as a Coping Mechanism 103 6.3 SIB: A Long-Term Reaction to Severe Trauma 105 6.4 SIB and Traumatic Memories 106 6.4.1 The Nature of the Traumatic Memory 106 6.4.2 SIB as a Coping Mechanism for Traumatic Memories 108 CoNTENTS xvii

6.5 SIB as a Means of Communication 112 6.5.1 Bodily Trauma and the Need for a New Language 112 6.5.2 No One Believes 114 6.5.3 Breaking the Silence 114 6.6 SIB as a Tool for Managing Dissociation 117 6.7 The Phenomenology of SIB 121 6.7.1 SIB at the Body-Schema Level: Being-in-a-Hostile-World 121 6.7.2 SIB at Body-Image Level: The Body-for-Itself-for-Others 122 6.7.3 SIB: Body-Image Versus Body-Schema 124 References 126

7 The Destructive Nature of Complex PTSD 131 7.1 The Complex Nature of PTSD 131 7.2 C-PTSD from a Phenomenological Perspective 134 7.3 Structural Dissociation 137 7.4 Toward an Understanding of Body-Disownership 142 7.5 Toward a Cognitive Model of Body-Disownership 144 References 146

Body-Disownership—Concluding Remarks 151

Appendices 155

Bibliography 167

Index 185 List of Figures

Fig. 3.1 Three levels of the sense of body-ownership 36 Fig. 3.2 The phenomenology of autoscopic experiences 37 Fig. 3.3 Flexibility of the sense of body-ownership 48 Fig. 3.4 Body-as-subject vs. body-as-object 48 Fig. 6.1 Trade-off between dissociation and self-injuring behavior 121 Fig. 7.1 The deadly outcomes of trauma type II 143 Fig. 7.2 Sense of body-ownership that is too strong 145

xix Book Abstract

Severe and ongoing trauma can result in impairments at the body- schema level. In order to survive, trauma victims conduct their lives at the body-image level, thus producing a mismatch between body-schema and body-image. In turn, as in the case of somatoparaphrenia and BIID, this incongruity can result in body-disownership, which constitutes the very essence of the long-term outcomes of severe and ongoing trauma.

xxi CHAPTER 1

Introduction

1.1 when the Body Is the Enemy— Améry’s Basic Intuition Jean Améry survived the concentration camps of Auschwitz and Buchenwald and was later liberated at Bergen Belsen. In 1978, he took his own life. According to his own testimony, his suicide cannot be detached from his experiences at the concentration and death camps. Indeed, these experiences led him to claim that only under torture does one experience the body for the frst time as totally one’s own: “Whoever is overcome by pain through torture experiences his body as never before” and thus, “only in torture does the transformation of the person into fesh become complete” (Améry, 1980, p. 33). More precisely, in extreme circumstances victims experience the body as being too much their own. They have a sense of over-presence, or in cognitive terms, their sense of body-ownership is too strong. In effect, not only do victims completely identify with their body, but also they are reduced solely to the body: “the tortured person is only a body, and nothing else beside that” (p. 33). The main consequence of this reduction is that the individual identifes the body as the source of intolerable suffering and pain: “Body Pain Death” (p. 34). The main contention of this book is = = that this equation can trigger the development of a destructive cognitive mechanism which seeks to destroy the victim’s body as the source of suffering: “When the whole body is flled with pain, we try to get rid of the

© The Author(s) 2018 1 Y. Ataria, Body Disownership in Complex Posttraumatic Stress Disorder, https://doi.org/10.1057/978-1-349-95366-0_1 2 Y. ATARIA whole body” (Schilder, 1935, p. 104). Throughout the book, the term “body-disownership” is used to describe this cognitive mechanism. This book’s aim is to describe body-disownership on the cognitive and phenomenological levels and to demonstrate that this mechanism is responsible for the development of complex posttraumatic symptoms.

1.2 disownership Scholarly literature discusses disownership of body parts (de Vignemont, 2007, 2010, 2011, 2017), for example the case of somatoparaphrenia, defned as a “delusion of disownership of left-sided body parts” (Vallar & Ronchi, 2009, p. 533). Those who develop such a delusion strongly believe that a particular body part does not belong to them but rather to someone else. Another such condition, known as body integrity identity disorder (BIID), is defned as a persistent and ongoing desire to undergo amputation, which often presents as an attempt to adjust one’s actual body to one’s desired body (First, 2005). A phenomenological investigation of cases of somatoparaphrenia and BIID reveals inconsistencies at the body-schema level as well as between body-schema and body-image. Gallagher (2005) argues that “body- image and body-schema refer to two different but closely related systems.” While body-image can be defned as a “system of perceptions, attitudes, and beliefs pertaining to one’s own body,” body-schema is “a system of sensory-motor capacities that function without awareness or the necessity of perceptual monitoring” (p. 24). In effect, “bodily experience involves a complex integration of (a) automatic, bottom-up sensory and organisational processes (body-schema) with (b) higher order, top-down bodily and perceptual representations (body-image)” (Giummarra, Gibson, Georgiou-Karistianis, & John, 2008, p. 146). When the intentional structure is directed toward the body-as-an-object of perception, we are directed to the body-image and not the body-schema. To rephrase this notion, when we contemplate our body from a third-person perspective (3PP), we are contemplating our body-image. Gallagher (2005) advocates the notion of a double dissociation between body-image and body-schema. This disparity can also be described in terms of the discrepancy between the lived-body (Leib) or body-as-subject (body-schema) and the physical body (Körper) or body- as-object (body-image). 1 INTRODUCTION 3

Leib Körper First-person perspective (1PP) Third-person perspective (3PP) Body-as-subject Body-as-object Body-schema Body-image

The left and right columns represent different kinds of perspectives of the human body. Both sides are essential to the twofold structure of the human body. Furthermore, although it may seem that these two aspects are completely separate, in practice this kind of segregation is somewhat artifcial. This book uses terms such as Leib, 1PP, body-as-subject and body-schema somewhat synony- mously although each one of has its own unique features. In particular, whereas Leib is a classic term in the phenomenological world, body-schema is more cognitive. The same applies for the right column of this table: Körper, 3PP, body-as-object, and body-image: Körper is a classic term in the phenomenological world, while body-image is more cognitive

Having clarifed these concepts, let us return to the cognitive incon- gruities responsible for the development of limb-disownership. On the cognitive level, a twofold incongruity appears to be necessary for limb-disownership to develop. The frst-order contradiction is between sense of body-ownership (SBO), that is “the sense that I am the one who is undergoing an experience,” and sense of agency (SA), that is, “the sense that I am the one who is causing or generating an action” (Gallagher, 2000, p. 15). These two independent yet closely related mechanisms routinely work together. Yet if SBO and SA collide, the result is contradiction at the body-schema level. In the case of somatoparaphrenia, the individual loses SA but not SBO, while in the case of BIID the individual loses SBO but not SA.

Sense of agency (SA) Sense of body-ownership (SBO) Somatoparaphrenia + − Body integrity identity + − disorder (BIID)

Yet, this frst-order contradiction between SBO and SA at the body- schema level is insuffcient for limb-disownership to develop. Rather, a second-order contradiction is also necessary. To understand this second-order contradiction, we must frst differentiate between feeling and judgment—between knowing this is my body and feeling it. This incongruity can be defned in terms of the discrepancy between one’s feeling of body-ownership at the body-schema level and one’s judgment 4 Y. ATARIA of body-ownership at the body-image level. A similar gap exists between the feeling of agency (body-schema) and the judgment of agency (body-image). Feelings of agency and ownership are non-conceptual and implicit, emerging at the body-schema level. In contrast, judgments of agency and ownership require an interpretive judgment based on one’s conceptual framing of the situation and one’s beliefs. We can therefore explain the second-order contradiction in terms of an inconsistency between one’s feeling of agency or ownership (body- schema) and one’s judgment of agency or ownership (body-image). As this mismatch between body-schema and body-image becomes more intolerable, the consequences become increasingly acute. In effect, the second-order contradiction can only emerge if there exists a frst-order contradiction at the body-schema level. Nevertheless, the frst-order contradiction alone is not suffcient for limb-disownership to occur.

OwnershipAgency Body-Schema Feeling of Feeling of ownership agency

Second order contradiction First order contradiction

Body-Image Judgment of Judgment of ownership agency

This double dissociation between body-schema and body-image is the key to understanding the book’s central argument. If two different mechanisms were indeed at work, it would be possible for one to sustain damage while the other remains intact. Yet the fact that these mechanisms are detached from one another does not mean they do not engage in dialogue. Indeed, they work together on a regular basis; their synchronization enables us to act naturally, automatically, and unconsciously in-the-world. Hence, if a problem arises in one of these mechanisms, their synchronization will be gravely harmed, with varied and grievous consequences. This book seeks to show that a possible consequence of a problem in one of these body maps is the loss of the synchronization between body-schema and body-image. The long-term result of this loss can be limb-disownership—the sense that a body part, or even the entire body, does not belong to us. In certain cases, this can motivate our desire to 1 INTRODUCTION 5 rid ourselves of this body part, or even the entire body. Hence, the main contention of this book is that in the case of severe and ongoing trauma, the mechanism that attacks individual body parts begins to attack the entire body. To understand this notion, we must take one step backward and analyze trauma from the phenomenological and cognitive perspectives, according to which the mind, the body, and the world are considered a single and cohesive dynamic system.

1.3 trauma—The Collapse of the Knowing-How Structure Psychological trauma (hereinafter: trauma) is an emotional response to a dreadful event such as an accident, rape, or natural disaster. Shock and denial are typical immediately following the event. While this is the classic defnition of trauma (e.g., by the American Psychological Association), this book defnes trauma somewhat differently, embracing the enactive approach to perception. When perceiving the world, we cannot bypass our body because it “is inescapably linked with phenomena” (Merleau-Ponty, 2002, p. 354). Thus, not only is the body “our general medium for having a world” (p. 169) and not only are we “conscious of the world through the medium of my body” (p. 95), but in fact we are doomed to be thrown into the world on a bodily level: “we are our body… we perceive the world with our body… we are in-the-world through our body” (p. 239). Indeed, according to Merleau-Ponty, we are “at grips with the world” (p. 353) through and with the living-body (Leib), that is, at the body- schema level. When the coupling level of the sensorimotor loop is high, we have a strong grip on the world. Our pre-refective expectations are confrmed in every movement, and we perceive the world directly. In contrast, when the coupling level of the sensorimotor loop is low, our grip on the world is weak. Infuenced by Merleau-Ponty, Noë (2004) suggests that “perception is not something that happens to us, or in us. It is something we do,” and thus, “the world makes itself available to the perceiver through physical movement and interaction” (p. 1). More precisely, perception is the exercise of sensorimotor knowledge, which can be defned as knowing-how or practical knowledge and explained in terms of mastering a skillful activity. In practice, for us to “master” a skillful activity means to be “‘attuned’ to the ways in which one’s movements will affect the character of input” (O’Regan & Noë, 2001, p. 84). 6 Y. ATARIA

To perceive, we require the pre-refective ability to master our movements and predict how the world will “react” to these movements according to a set of sensorimotor laws. The inability to do so diminishes our ability to perceive. We simply do not know what to do or how to do it. When we can no longer predict (pre-refectively) the outcomes of our actions, our ability to master a situation is weakened. Our practical knowledge is damaged, rendering us incapable of tuning into sensorimotor contingencies or acting based upon sensorimotor laws. In turn, our very ability to perceive and engage with the world is damaged, and our grip on the world is minimal. In this situation, the body is no longer a knowing body. The experience of wearing inverting (left/right–up/down) glasses (Stratton, 1896) may help us understand the collapse of practical knowledge. Scholars generally tend to emphasize the human ability to adapt— to learn how to handle the world—while wearing inverting glasses. Yet, during the frst few hours of wearing these glasses, we have the strange sense that everything is left–right inverted, and because our normal capacities for engagement have been disrupted, certain actions prove impossible (Degenaar, 2013). We lose our ability to master our actions, and as a result, the sensorimotor loop is broken. In extreme cases, this may lead to a complete inability to function. Indeed, even after a few days of practice, Degenaar (2013) remained unable to perform simple tasks:

I often reached in the wrong direction, even when I knew where objects in my room were located. Vision tends to overrule knowledge, and to a certain extent, even habits are cancelled or transformed. A notable behavioral impairment expressed itself when I attempted to reposition a cup that was standing too close to the edge of a table. It was almost impossible to fnd the right direction. Trying to correct the movement, I instead altered it in the wrong way. Even days later, cutting tomatoes still had a similar effect: the appropriate orientation of the knife was almost impossible to bring about. (p. 379)1

In extreme cases, the collapse of the knowing-how structure may cause the individual to lose the knowledge necessary for perception. The action–perception circuit is broken, causing fundamental damage to

1 Throughout the book, quotations representing frst-person subjective experiences are italicized. In these quotations, boldface font is used to emphasize particular segments. 1 INTRODUCTION 7 our ability to predict and possibly distorting our perception. According to sensorimotor theory, perception is based on the know-how structure. Our ability to remain systematically tuned into our environment based on a set of laws or sensorimotor contingencies enables us to perceive. Hence, damage to this sensorimotor circuit weakens our ability to perceive. In perceptual terms, though only in perceptual terms, we may compare trauma to the experience of someone watching a Ping-Pong game on a wide screen. This individual, who is wearing inverting glasses for the frst time and cannot remove them, is forced to move his head to track the movement of the ball. Indeed, trauma is akin to Degenaar’s feeling when he frst wore the inverting glasses: “On the frst day of wearing the glasses I got sick” (2012, p. 151). Yet unlike in Degenaar’s case, in most cases, although as we will see there are exceptions, the victim does not have suffcient time to learn how to perceive the world through the “glasses” of trauma. During severe trauma, the ability to perceive is fundamentally damaged simply because the individual lacks the know-how and is completely unable to adapt. For the victim, the feeling of nausea described by Degenaar becomes intolerable. The system’s inability to update itself and the collapse of the knowing- how structure form the very core of the traumatic experience. In cases of prolonged and ongoing trauma, the victim’s sensorimotor loops undergo radical changes. Hence, in order to survive the victim must construct a new system connecting between expectations and actual possible outcomes, thus modifying the knowing-how structure. In the long term, however, the outcomes can be devastating because the very structure of the sensorimotor loops has become embedded within trauma. Considering this in terms of someone who cannot see the world without wearing inverting glasses—such an individual perceives the world through the trauma, not only during the traumatic event but also after it has ended. Hence, to say that The Body Keeps the Score (Van der Kolk, 2014) or that The Body Bears the Burden (Scaer, 2007) is to say that the structure of the sensorimotor loops has become embedded within the trauma and cannot release itself from that moment. Indeed, the individual cannot remove the inverting glasses. The implications of this notion are far-reaching: Traumatic experiences can cause changes at the body- schema level. Hence, it is quite clear why prolonged and severe trauma can result in an inability to be-in-the-world: In the wake of trauma, the world has become a painful place. As Améry (1980) puts it, “Whoever 8 Y. ATARIA was tortured, stays tortured. Torture is ineradicably burned into him” (p. 34).

1.4 complex Posttraumatic Stress Disorder Trauma survivors who develop posttraumatic stress disorder (PTSD) often relive the traumatic event via intrusive memories, fashbacks, and nightmares. They avoid anything which reminds them of the trauma and experience intense anxiety that disrupts their lives. Complex PTSD (C-PTSD), also referred to as Disorders of Extreme Stress Not Otherwise Specifed (DESNOS), includes the core symptoms of PTSD. As Herman (1992a, b) stresses, the classic PTSD symptoms fail to explain the diverse symptoms that some posttraumatic survivors develop, in particular (a) emotion regulation diffculties; (b) disturbances in relational capacities; (c) dissociation; (d) adverse effects on belief systems; and (e) somatic distress or disorganization. C-PTSD usually results from exposure to repeated or prolonged trauma, such as internment in prisons, concentration camps or slave labor camps, as well as incest (i.e., trauma type II). Not only is the symptomatology of those suffering from C-PTSD apparently more complex than that of those suffering from simple PTSD but victims of ongoing trauma at times also develop characteristic personality changes, including identity distortions. Furthermore, in these severe cases survivors are highly vulnerable to repeated harm, not merely by others but literally at their own hands. In phenomenological terms, C-PTSD can be described as a situation in which one can no longer be-in-the-world or feel that one belongs to the world. Instead, the survivor develops a sense of alienation from the world. Alienation from the world and alienation from the body are thus identical (Ratcliffe, 2015). As Ratcliffe (2008) further stresses, “when one feels ‘at-home’ in-the-world, ‘absorbed’ in it or ‘at one with life’, the body often drifts into the background” (p. 113). Indeed, during the course of everyday life, we feel a sense of belonging to the world. Yet, when we can no longer feel at-home within the world, the entire body becomes increasingly salient: “The body is no longer a medium of experience and activity, an opening onto a signifcant world flled with potential activities.” Instead, “it is thing-like, conspicuous, an object… an entity to be acted upon” (Ratcliffe, 2008, p. 113). Moreover, “at times of illness one may experience one’s body as more or less ‘unuseable.’ It can no longer do what once it could.” Hence, “the sick body may be 1 INTRODUCTION 9 experienced as that which ‘stands in the way,’ an obstinate force interfering with our project” (Leder, 1990, p. 84). When the body becomes an obstacle, the equilibrium between the lived-subjective body and the dead-objective body is disrupted, tipping toward the body-as-object. As noted, we are pre-refectively connected to the world at the body-schema level. Under these conditions, the sensorimotor loops are tightly coupled and we possess a strong grip on the world. During trauma, in contrast, the coupling of the sensorimotor loops loosens, in turn weakening our grip on the world. This weakened grip results from impairment at the body-schema level, explaining, at least partially, the feeling that the body becomes an obstacle, a defective tool, an IT. Under such circumstances, the individual exists at the level of body-image. Considering this, we now return to C-PTSD. In phenomenological terms, C-PTSD can be defned as a condition in which the body becomes an IT. The victim can no longer exist at the level of the living-body or the body-schema; in this situation, the world becomes inaccessible, and as a result, one can no longer be-in-the-world. Instead, the survivor exists at the level of the body-as-object or body-image (see table One). Ultimately, this gap between body-schema and body-image becomes unbridgeable, and an enmity develops between the two. We already noted that a mismatch between body-schema and body- image (second-order contradiction) is a necessary condition for the development of limb-disownership. We also saw that C-PTSD can be defned in terms of discrepancy between body-schema and body-image. This discrepancy, in turn, can lead to the development of body-disownership which, as this book seeks to argue, forms the very core of C-PTSD.

1.5 outline of the Book Chapter 2 lays the philosophical groundwork for the entire book. Based on the philosophy of Merleau-Ponty, it describes the twofold structure of human beings, who are at once both subjects and objects. This chapter further focuses on the discrepancy between body-schema and body- image. Body-schema represents our initial presence in-the-world via our bodies from an egocentric, frst-person perspective (1PP). Body-image, in contrast, represents the way in which we perceive our bodies from the outside, from a 3PP. To sharpen this distinction, the chapter examines the famous case of Ian Waterman, a man who lost his body-schema completely and relies on his body-image to function in-the-world. The last 10 Y. ATARIA part of the chapter examines the meaning of belonging or not-belonging to this world. Chapter 3 comprehensively examines the SBO in phenomenological terms, focusing on instruments and prostheses through the lens of the famous rubber hand illusion (RHI) experiment (Botvinick & Cohen, 1998). Thereafter, the chapter discusses SBO at the level of the entire body, paying particular attention to Blanke’s research on autoscopic phenomena. In addition, it examines the phenomenology of depersonalization and, based on this analysis, argues that despite being fexible, under extreme conditions SBO may collapse. Moreover, this chapter also refers to various research studies which support the claim that 1PP is a more basic mechanism than SBO. Chapter 4 describes the reciprocal relations between SBO and SA. Whereas we ordinarily experience these together, various pathological conditions suggest they can be viewed as two different, although not independent, mechanisms. The chapter shows that incongruity between SBO and SA can result in the anarchic hand syndrome or the alien hand syndrome. Based on this observation, it explores the development of limb-disownership and provides an in-depth phenomenological investigation of somatoparaphrenia and BIID. The chapter consequently demonstrates that body-disownership is not equivalent to a lack of SBO. Indeed, it is possible for body-disownership to appear together with, and not at the expense of, SBO. Furthermore, this chapter claims that body-disownership results from an incongruity between SBO and SA at the body-schema level. This frst-order contradiction can lead to a second-order contradiction between body-schema and body-image. More specifcally, the chapter demonstrates that somatoparaphrenia derives from a lack of SA combined with an intact SBO at the body-schema level and a denial of the loss of SA at the body-image level. Such a condition generates intolerable inner tension that can lead to body-disownership. In the case of BIID, in opposition, body-disownership emerges when a lack of SBO together with an intact SA at the body-schema level clashes with the individual’s undeniable rational judgment that this body is mine, based on facts from the body-image level. This mismatch can lead to a sense of the body’s over-presence, and in cognitive terms, an SBO which is too strong. This, in turn, can result in body-disownership. Chapter 5 draws upon the notion that trauma is characterized by feelings of helplessness and that during trauma the SA weakens. Based on interviews with victims of terror attacks and former Prisoners of War 1 INTRODUCTION 11

(POW) conducted according to the phenomenological approach (see Appendix for an in-depth discussion), this book contends that in order to function, the SBO must weaken to the point at which SA SBO ≈ (SA:SBO 1). While the SA and the SBO remain somewhat equivalent ≈ (SA:SBO 1), the individual retains the ability to function. Yet it is pos- ≈ sible that the SBO will not weaken suffciently or will weaken too much. In either of these cases, a gap emerges between the SA and the SBO at the level of body-schema: SA:SBO ≠ 1. As in the cases of somatoparaphrenia and BIID, this can result in limb-disownership. The same mechanism may be activated with respect to the whole body. Indeed, Améry’s (1980) description of his feelings while being tortured reveals the phenomenology of body-disownership. The last two chapters describe the possible long-term outcomes of body-disownership: self-injuring behavior (SIB) and C-PTSD. Chapter 6 provides an in-depth phenomenological analysis of SIB. The major argument in this chapter is that while in certain cases self-injuring behavior can be considered adaptive, on a deeper level it is based on the mechanism of body-disownership and has destructive results. Chapter 7 describes the attributes of C-PTSD while focusing on the interface between body-disownership, SIB, and structural dissociation. It attempts to demonstrate that these mechanisms, which often appear together, are based on a strong sense of hostility toward the body and that, among other things, this fnds expression in SIB. By means of a proposed cognitive model, this chapter explains, at least in part, the operational modes of the destructive mechanism of body-disownership.

References Améry, J. (1980). At the mind’s limits (S. Rosenfeld & S. P. Rosenfeld, Trans.). Bloomington: Indiana University Press. Botvinick, M., & Cohen, J. (1998). Rubber hand ‘‘feel’’ touch that eyes see. Nature, 391, 756. de Vignemont, F. (2007). Habeas corpus: The sense of ownership of one’s own body. Mind & Language, 22(4), 427–449. https://doi. org/10.1111/j.1468-0017.2007.00315.x. de Vignemont, F. (2010). Embodiment, ownership and disownership. Consciousness and Cognition, 20(1), 82–93. de Vignemont, F. (2011). A self for the body. Metaphilosophy, 42(3), 230–247. https://doi.org/10.1111/j.1467-9973.2011.01688.x. 12 Y. ATARIA de Vignemont, F. (2017). Mind the body. Oxford: Oxford University Press. Degenaar, J. (2012). Perceptual engagement. Antwerpen: University of Antwerp. Degenaar, J. (2013). Through the inverting glass: First-person observations on spatial vision and imagery. Phenomenology and the Cognitive Sciences, 13(2), 373–393. First, M. B. (2005). Desire for amputation of a limb: Paraphilia, psychosis, or a new type of identity disorder. Psychological Medicine, 35(6), 919–928. Gallagher, S. (2000). Philosophical conceptions of the self: Implications for cognitive science. Trends in Cognitive Sciences, 4(1), 14–21. Gallagher, S. (2005). How the body shapes the mind. New York: Oxford University Press. Giummarra, M. J., Gibson, S. J., Georgiou-Karistianis, N., & John, B. L. (2008). Mechanisms underlying embodiment, disembodiment and loss of embodiment. Neuroscience and Biobehavioral Reviews, 32(1), 143–160. https://doi.org/10.1016/j.neubiorev.2007.07.001. Herman, J. L. (1992a). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377–391. https:// doi.org/10.1002/jts.2490050305. Herman, J. L. (1992b). Trauma and recovery. New York: Basic Books. Leder, D. (1990). The absent body. Chicago: The University of Chicago Press. Merleau-Ponty, M. (2002). Phenomenology of perception (C. Smith, Trans.) London: Routledge and Kegan Paul. Noë, A. (2004). Action in perception. Cambridge: The MIT Press. O’Regan, K. J., & Noë, A. (2001). What it is like to see: A sensorimotor theory of perceptual experience. Synthese, 129(1), 79–103. Ratcliffe, M. (2008). Feelings of being. Oxford: Oxford University Press. Ratcliffe, M. (2015). Experiences of depression. Oxford: Oxford University Press. Scaer, R. C. (2007). The body bears the burden: Trauma, dissociation, and disease. New York: Haworth Medical Press. Schilder, P. (1935). The image and appearance of the human body. New York: International Universities Press. Stratton, G. M. (1896). Some preliminary experiments on vision without inver- sion of the retinal image. Psychological Review, 3(6), 611–617. Vallar, G., & Ronchi, R. (2009). Somatoparaphrenia: A body delusion. A review of the neuropsychological literature. Experimental Brain Research, 192(3), 533–551. https://doi.org/10.1007/s00221-008-1562-y. Van der Kolk, B. A. (2014). The body keeps the score. New York: Viking. CHAPTER 2

The Twofold Structure of Human Beings

2.1 the Twofold Structure of the Human Body We are our bodies. In Merleau-Ponty’s (2002) words, “I am not in front of my body, I am in it, or rather I am it” (p. 173). Yet by saying I am it, Merleau-Ponty in no way claims that humans can be reduced to the body’s physical elements (e.g., the corporeal body). Our bodies are not purely physical entities “but rather to a work of art” (p. 174). Merleau- Ponty strongly believes that the very structure of our existence as subjects within this world is rooted in our unique bodily structure—our simultaneous existence as both body-as-subject and body-as-object. The body-as-object is perceived from a third-person perspective (3PP) as a dead body (Körper) or a pure object. In contrast, the body-as-subject, or the living-body (Leib), is full of meaning. The body is a unique instrument which possesses particular capa bilities and limitations. Through this instrument, we are present in-the- world as active agents. Thus, “it is through my body that I understand other people, just as it is through my body that I perceive ‘things’” (p. 216). In fact, “I could not grasp the unity of the object without the mediation of bodily experience” (p. 235). However, it is not the body- as-object that enables us to engage with the world. Rather, we understand the world around us through the living-body; the lived-body shapes and is shaped by the environment in which it acts.

Merleau-Ponty believes that the twofold human body constitutes the very core of our existence as living subjects within the world:

In so far as, when I refect on the essence of subjectivity, I fnd it bound up with that of the body and that of the world, this is because my existence as subjectivity is merely one with my existence as a body and with the existence of the world, and because the subject that I am, when taken concretely, is inseparable from this body and this world. The ontological world and body which we fnd at the core of the subject are not the world or body as idea, but on the one hand the world itself contracted into a comprehensive grasp, and on the other the body itself as a knowing-body. (p. 475)

The essence of subjectivity can be explained in terms of the frst-person perspective (1PP) on the world from within our body. While we are in-the-world, we cannot avoid our own 1PP. To be present in-the-world through one’s body is tantamount to manipulating one’s environment through one’s body. For example, in order to discover the rotten parts of an apple, we hold the fruit in our hand and turn it around. The world calls for action. Our body as an instrument is also another object in-the-world. Yet it is a unique instrument, being with us always and never leaving us.1 Moreover, it is not an object which we can examine from the outside like any other object. Our body can never stand in front of us in our perceptual feld as other objects do. In fact, our body enables us to examine other objects in the perceptual feld from the outside, yet this remains impossible in the case of the body itself. We can shatter objects we encounter, break them down into smaller units, dissolve them, play with them, and even destroy them. When it comes to our own body, however, this is not possible. Thus, only within traumatic felds (in the widest sense, of course) such as the concentration and death camps or the Gulag, do humans become pure objects. Our body as an object in our perceptual feld fundamentally differs from all other objects. Our body transforms the perceptual feld from objective to subjective, so that it is always perceived from within the body, that is, from a 1PP. The world is thus our world, that is, a bodily world that holds us.

1 We must be careful not to read this sentence from a dualistic perspective but rather as the product of the limitations of language, a recurring problem in the writing of this book. 2 THE TWOFOLD STRUCTURE OF HUMAN BEINGS 15

Yet it would be a mistake to treat the perceptual feld as polar and existing only from a subjective perspective. As noted, our body is also an object among other objects. The best way to understand the twofold structure of our perceptual feld is through the sense of touch:

Tactile experience… adheres to the surface of our body; we cannot unfold it before us, and it never quite becomes an object. Correspondingly, as the subject of touch, I cannot fatter myself that I am everywhere and nowhere; I cannot forget in this case that it is through my body that I go to the world, and tactile experience occurs ‘ahead’ of me, and is not centred in me. It is not I who touch, it is my body; when I touch I do not think of diversity, but my hands rediscover a certain style which is part of their motor potentiality, and this is what we mean when we speak of a perceptual feld. (Merleau-Ponty, 2002, p. 369, my emphasis)

The perceptual feld encompasses a combination of subject and object. We are at the center of the world and part of the world, yet we are not identical to the pure objects around us. This preliminary sense of being- in-the-world possesses no sense of who. Rather, the feld of perception is a blend, in which things are “inseparable from a person perceiving it”. Within this blend, the body can serve as a “stabilized structure” (p. 373); namely, the body organizes the feld from a certain perspective: “My point of view is for me not so much a limitation of my experience as a way I have of infltrating into the world in its entirety” (p. 384). We are simultaneously object and subject, perceiver and perceived. So long as this structure remains intact, our body cannot become just another object in space. This twofold structure allows us to feel separate from the world, yet as human beings we are an inseparable and indistinguishable part of the world. To explain this notion, Merleau-Ponty introduces the concept of Chiasm in his unfnished book, The Visible and the Invisible. This concept is rooted within the “paradoxical fact that though we are of the world, we are nevertheless not the world” (Merleau-Ponty, 1968, p. 127). Merleau-Ponty draws a strong link between the bodily subject and the (bodily) world, and in so doing develops the concept of fesh 2: The perceiving subject is completely absorbed in corporeal reality. This reality both envelops and invades the subject, just as the subject investigates, gropes,

2 Merleau-Ponty introduced the concept of fesh late in his writing. 16 Y. ATARIA and invades reality. Merleau-Ponty uses the concept of fesh to describe our being-in-the-world as integral rather than in the polarized terms of subject versus object. We are woven into the world, and the boundary between body and world is vague and hazy. This does not negate the existence of a subject but rather indicates that the boundary between subject and world is fuid. We invade the world and the world invades us, just as food, once an alien object, becomes part of us. Nevertheless, a sense of boundaries is necessary because, as De Haan and Fuchs (2010) emphasize, “the loss of self is often accompanied by a feeling of being somehow too open to the world, of having a too ‘thin skin’.” Such a feeling may “lead to experiences of transitivism, of the per- meability of boundaries between the self and others, or the self and the world.” As a result, “other people and the world may be experienced as intrusive, invading the personal sphere” (p. 329). Thus, when one’s sense of boundaries becomes too fexible, a sense of helplessness is liable to develop. Indeed, this is demonstrated by the cases of two patients suffering from schizophrenia (De Haan & Fuchs, 2010), S. N. and L. N. The former describes the following experience: “My skin is extremely thin, especially when it concerns me personally. [I feel vulnerable] like a rabbit, lying on its back.” L. N. adds: “I am too sensitive. [I feel] helpless, sometimes. I think that I cannot defend myself” (De Haan & Fuchs, 2010, p. 329). Dorfman (2014) points out that Merleau-Ponty tries to take the ambiguity of our existence to its limits by stretching it into a zone wherein the distinctions between inside and outside, between subject and object, are almost nonexistent. Note, however, that “there are two extreme poles between which my attitude towards the body oscillates: total separation, on the one hand, and total immersion, on the other”. While at the pole of total separation the body becomes “a thing in-the- world: an external and rather hostile object,” at the other extreme of total immersion, “objectivity disappears and I feel an inseparable and mutual belonging between myself and my body, as well as between my body and the world” (p. 69). Ordinarily, the body-as-subject and the body-as-object are in equilibrium. Any change in this equilibrium marks a change in our way of being-in-the-world: This change “appears as an object of conscious attention, particularly when it is inadequate for a task to be performed, be it by a lack of capacity, fatigue, illness or numbness, and whenever it becomes an object for others to whom I feel exposed.” Under such circumstances, the lived-body ceases to be implicit; instead, “the body’s 2 THE TWOFOLD STRUCTURE OF HUMAN BEINGS 17 performance is made explicit and may often be disturbed” (Fuchs & Schlimme, 2009, p. 571). This tension between the body-as-subject and the body-as-object materializes in the form of structured ambiguity. Note, however, that Merleau-Ponty does not try to avoid this tension because it emerges from the “undividedness of the sensing and the sensed”. Instead he states:

The enigma derives from the fact that my body simultaneously sees and is seen. That which looks at all things can also look at itself and recognize, in what it sees, the ‘other side’ of its power of looking. It sees itself seeing; it touches itself touching; it is visible and sensitive for itself. (Merleau-Ponty, 1964, p. 162, my emphasis)

Essentially, according to Merleau-Ponty, this tension is necessary for our existence: “A human body is present when, between the see-er and the visible, between touching and touched, between one eye and the other, between hand and hand a kind of crossover occurs” (p. 163). Yet if this structure were to collapse, the very essence of being human would lose its meaning and there “would not be a human body.” Moreover, collapse of the subject–object structure marks not only the end of the human body but in fact the end of humanity: “Such a body would not refect itself; it would be an almost adamantine body, not really fesh, not really the body of a human being. There would be no humanity” (p. 164). As will become clear later in the book, under extreme circumstances, particularly during severe and ongoing trauma, this twofold subject– object structure may collapse. The outcome can be quite destructive precisely because we would cease to be human. To accept this notion, we must realize that we are engaged with the world and absorbed within it through our body. We are thrown into the world at the body- schema level, and thus, any impairment on this level initiates a process of dehumanization.

2.2 Body-Schema and Body-Image

2.2.1 Theory of Body-Schema—Theory of Perception How are we so closely connected to the world? In response to this question, Merleau-Ponty contends that we perceive the world through our bodies. Namely, perception of the world cannot bypass our bodies because 18 Y. ATARIA the “body is inescapably linked with phenomena” (Merleau-Ponty, 2002, p. 354). Thus, not only is the body “our general medium for having a world” (p. 169) and not only are we “conscious of the world through the medium of my body” (p. 95), but we are in fact doomed to be thrown into the world on a bodily level: “we are our body… we perceive the world with our body… we are in-the-world through our body” (p. 239). Indeed, according to Merleau-Ponty, we are “at grips with the world” (p. 353) through the knowing body. Based on Merleau-Ponty (2002), Gibson (1979), Varela, Thompson, and Rosch (1991), and Noë (2004) argues that perception is a method of active engagement with the environment: “perception is not something that happens to us, or in us. It is something we do… the world makes itself available to the perceiver through physical movement and interaction” (p. 1). According to the enactive approach, “perceiving is a kind of skillful bodily activity” (p. 2). More specifcally, perceiving is the exercise of sensorimotor knowledge, which O’Regan and Noë (2001a) refer to as knowledge of sensorimotor contingencies acquired while exploring the world in an enactive manner. These contingencies play a fundamental and con- stitutive role in the theory proposed by O’Regan and Noë (2001a). This so-called knowledge, which can be defned as knowing-how or practical knowledge,3 can be explained in terms of mastering a skill. In practice, to “master” a skill one must be “‘attuned’ to the ways in which one’s movements will affect the character of input” (O’Regan & Noë, 2001b, p. 84). This ability to “master” is implicit and pre-refective; hence, as O’Regan (2010) argues, it remains beyond words. The following example may clarify the matter:

Consider a missile guidance system. When the missile is following an airplane, there are a number of things the missile can do which will result in predictable changes in the information that the system is receiving. For example, the missile can go faster, which will make the image of the airplane in its camera become bigger. Or it can turn, which will make the image of the airplane in its camera shift. We shall say that the missile guidance system has mastery of the sensorimotor contingencies of airplane tracking, if it ‘knows’ the laws that govern what happens when it does all the things it can do when it is tracking airplanes. (O’Regan & Noë, 2001b, p. 81)

3 As opposed to knowing-that (Ryle, 1949). 2 THE TWOFOLD STRUCTURE OF HUMAN BEINGS 19

Thus, the statement that the body constitutes our general medium for having a world means that in the process of perceiving, objects live through the body: “the synthesis of the object is here effected, then, through the synthesis of one’s own body” (Merleau-Ponty, 2002, p. 238). Merleau-Ponty’s famous statement that “the theory of the body-schema is, implicitly, a theory of perception” (p. 239) indicates that we perceive the world via changes in our body-schema. In turn, the body-schema ties us to the world, or better put, it is at the body-schema level that we are being held by the world.

2.2.2 Body-Schema Versus Body-Image: Double Dissociation Gallagher (2005) maintains that “body-image and body-schema refer to two different but closely related systems” (p. 24). While body-image can be defned as a “system of perceptions, attitudes, and beliefs pertaining to one’s own body” (p. 24), body-schema is “a system of sensory-motor capacities that function without awareness or the necessity of perceptual monitoring” (p. 24). Whereas the body-image can become the contents of consciousness and the object of one’s attention, the body-schema shapes the structure of consciousness “but does not explicitly show itself in the contents of consciousness” (p. 32). Basically, “bodily experience involves a complex integration of (a) automatic, bottom-up sensory and organisational processes (body-schema) with (b) higher order, top-down bodily and perceptual representations (body-image)” (Giummarra, Gibson, Georgiou-Karistianis, & John, 2008, p. 146). When the intentional structure is directed toward the body-as-an-object of perception as if this body were simply any other object in space, we are referring to body-image. When considering our body from a 3PP, we think about our body-image. Thus, we can defne body-image using the following categories:

1. The perceptual experience of one’s own body; 2. The conceptual understanding of the body in general; and 3. The emotional attitude toward one’s own body.

The process by which the body occupies our attention as though from a third-person perspective usually requires voluntary and deliberate refection upon the body. Indeed, when the body in-itself serves as the object being perceived, the short-term body-image grabs our attention and per- ceptional feld. As Gallagher (2005) notes: “The body-image consists of 20 Y. ATARIA a complex set of intentional states and dispositions—perceptions, beliefs, and attitudes—in which the intentional object is one’s own body” (p. 26). At the body-image level, the boundaries are clear, solid, rigid, and well defned. In contrast, at the body-schema level these boundaries are less clear, less easily located, and more fexible because “body-schema functions in an integrated way with its environment” (Gallagher, 2005, p. 37). The body-schema, which “functions in a more integrated and holistic way” (p. 26), allows us to feel that “my body is a thing among things; it is one of them. It is caught in the fabric of the world… the world is made of the very stuff of the body” (Merleau-Ponty, 1964, p. 163). In turn, when the body-schema functions properly, one’s sense of boundaries is fexible and the body remains transparent in the course of perceiving the world. Drawing on various different pathological cases, Gallagher (2005) demonstrates a double dissociation between body-image and body-schema. He reveals that in some cases, defects at the body-image level do not cause problems at the body-schema level. Furthermore, in other cases, defects at the body-schema level do not infuence body-image. Such pathological cases strongly support Gallagher’s double dissociation principle. With this in mind, let us examine Ian Waterman’s case. At the age of 19, Ian Waterman suffered a severe bout of gastric fu. During this illness, his body produced antibodies to fght the infec- tion, which then attacked his nerves. As a result, Ian suffers from differentiation and lost the sense of touch and proprioception below the neck. Simply put, Ian has lost his body-schema. Ian’s case enables us to understand, at least to some extent, the experience of being-in-the- world without a body-schema. Ian is unable to feel his posture, his sense of movement, or the location of his limbs. Yet by relying exclusively on visual and cognitive cues, he is able to carry out actions such as walking and driving (Cole, 2005; Cole & Paillard, 1995; Gallagher & Cole, 1995). Based on Ian’s case study, Gallagher (2005) suggests that body- schema rather than body-image allows us to:

1. move and act in-the-world automatically, without consciously thinking about how to move; 2. control our body effortlessly; 3. feel that this body is our own; 4. feel comfortable with our body; 2 THE TWOFOLD STRUCTURE OF HUMAN BEINGS 21

5. have confdence in our body: be sure that our body will react appropriately in different kinds of situations, even unfamiliar ones; 6. forget that we have a body; 7. decide to do something and simply implement our wishes, without awareness of how this is accomplished; and 8. feel that we possess a frst-person egocentric perspective upon the world.

Clearly, A fundamental question is how can Ian move his body lacking these abilities? According to Gallagher (2005), Ian has substi- tuted his body-schema with a virtual body-schema consisting of “a set of cognitively driven motor processes.” Yet, “this virtual schema seems to function only within the framework of a body-image that is consciously and continually maintained,” because, “if he is denied access to a visual awareness of his body’s position in the perceptual feld, or denied the ability to think about his body, then, without the framework of the body-image, the virtual body-schema ceases to function” (p. 52).4 Under such circumstances, Ian’s body would become an intentional object—an obstacle and a burden. The same may be true in states defned as liminal, among them fatigue, pain, sickness, certain patholo- gies, and other stress situations. Through an analysis of this case, Gallagher provides some critical observations regarding the double dissociation between body-schema and body- image which are highly signifcant to the present discussion. As we will see later on, Ian’s phenomenology can improve our understanding of posttraumatic symptoms. Survivors of severe and ongoing trauma suffer from defcits at the body-schema level, yet not necessarily at the body-image level, forcing survivors to be engage with the entire world using (only) their body-image. Consequently, the equilibrium between body-as-object

4 Yet it would be a fundamental mistake to ignore the important role which body-image plays in the structure of perception. For example, in the case of anorexia, body-image can shape, at least to some extent, the structure of the perceptual feld. Furthermore, Fanon’s (1968) phenomenological investigation of the “other” (the black man in his case) shows that we must explore much more precisely the link between body-image and body-schema. Thus, if we accept O’Shaughnessy’s (2000) differentiation between short-term body-image and long-term body-image, we can plausibly suggest that long-term dispositions (perceptions, beliefs, and attitudes) toward the body can prenoetically shape the structure of the perceptual feld. In such cases, long-term body-image remains hidden while perceiving the world—as does body-schema. 22 Y. ATARIA and body-as-subject begins to tip: The body-as-object begins to dominate the body-as-subject. Any change in this equilibrium is refected in how we are thrown into the world, as Ratcliffe (2008) notes: This change is experienced as “a changed relationship to the world as a whole, an alteration in the possibility space that one fnds oneself in” (p. 124). Indeed, any shift in the equilibrium between body-as-subject and body-as-object immediately affects the what-I-can dimension.

2.2.3 Nothing Is Within Our Reach When the equilibrium tips toward body-as-object, the sense of I-can decreases: “The conspicuous body is, at the same time, a change in the sense of belonging to the world, often a retreat from a signifcant project in which one was previously immersed, a loss of practical possibilities that the world previously offered” (p. 125). Indeed, the world is a feld of possibilities—a phenomenal feld in which we know what we can achieve. What I-can-(or cannot)-do defnes the phenomenal feld as an arena that facilitates some activities and negates others: “The world calls forth certain activities and it also appears as a space of possibilities involving others, which are not solicited in an automatic fashion but still appear as enticing” (Ratcliffe, 2008, p. 126). Let us explain this notion further using the concept of affordance. According to Gibson (1979), affordance is “something that refers to both the environment and the animal in a way that no existing term does. It implies the complementarity of the animal and the environment.” Moreover, he continues: “the affordances of the environment are what it offers the animal, what it provides or furnishes, either for good or ill” (p. 127). Affordance can also be described in terms of potential for action: “Different layouts afford different behaviors for different animals, and different mechanical encounters” (Gibson, 1979, p. 128). Continuing this line of thought, Gallagher and Zahavi (2014) argue that “when I perceive something, I perceive it as actionable,” thus, in essence, “such affordances for potential actions (even if I am not planning to take action) shape the way that I actually perceive the world” (p. 211). We can thus describe the phenomenal feld in terms of motor intentionality at the body-schema level, an “actional feld” (Leder, 1990, p. 18). Moreover, our possibilities in this world demarcate our phenomenal feld and defne our most basic existential feelings. For instance, a phenomenal feld in which I cannot perform, an I-Can-Not kind of feld, 2 THE TWOFOLD STRUCTURE OF HUMAN BEINGS 23 generates a sense of passivity: “certain feelings of passivity before the world, which sometimes take the form of a painful estrangement, are constituted by the sense that it is a world of possibilities for others but not oneself” (Ratcliffe, 2008, p. 128). In our daily life, we all possess a certain boundary which represents the shift from the I-can to the I-Can-Not. Beyond this hazy and fexible boundary, we cannot perform. When things go wrong—particularly in the case of life-threatening events—our boundaries narrow and our practical feld shrinks, leading to a sense of passivity and even helplessness. In this situation, the world is no longer within our reach. As was noted in the introduction, trauma can cause damage to the body-schema, in turn leading to a reduction of the I-can feld. The long- term outcomes of this damage may include an inability to be-in-the- world at the body-schema level. As a result, the victim exists only at the body-image level. The world of the posttraumatic survivor shrinks, the boundaries become impenetrable, and the world is no longer accessible. Hence, in the case of the posttraumatic survivor who exists at the body-image level, the I-Can-Not extends over and above the I-can. In turn, the very structure of the phenomenal feld undergoes such extreme changes that the survivor feels nothing is within reach: a shift from a sense of belonging to a sense of not-belonging.

2.3 what Not-Belonging Feels Like We can also describe the disparity between body-schema and body-image in terms of the discrepancy between the lived-body (Leib) or body-as-subject and the physical body (Körper) or body-as-object. When the lived-body becomes more dominant, the sense of belonging to the world increases. When we are in-the-world, our body is not perceived as an object but rather as the lived-body that allows us to perceive the world; in our daily life, the body is forgotten in favor of the world. In this sense, the body is absent from the experience; it is not missing but rather transparent. The absent body allows us to feel as if we perceive the world directly. In turn, when the body becomes less transparent, and hence more evident in our experience, it begins to resemble a body-as-object rather than a body-as- subject: less a lived-body and more a dead body. Ordinarily, when the body is healthy and circumstances do not place it at the center of our attention, the body is immersed within the world and there is no clear distinction between the two. Rather, the boundaries 24 Y. ATARIA are liquid: “the overall experience of being-in-the-world is inseparable from how one’s body feels in its surroundings” (Fuchs & Schlimme, 2009, p. 571). When one feels a sense of belonging to the world, the distinction between self and world becomes much less obvious. Ratcliffe (2008) further suggests that the sense of belonging is much closer to our daily life experience. We are accustomed to feeling at-home within the world. He continues by saying that “it is curious that so many accounts of perception emphasize the self-world boundary, the distinction between subject and object or the separation between bodily and non-bodily” (p. 94). Instead of this self–world boundary approach, Ratcliffe suggests that “when we are comfortably passive or involved in a smooth context of bodily activity, neither the body nor the physical boundary between the body and everything else is especially conspicuous.” Instead, “body and world are, to some extent at least, undifferenti- ated” (p. 95, my emphasis). Thus, “without a frm boundary between internally and externally directed senses, it is not possible to cleanly separate proprioception from perception of things outside of the body” (p. 124). Here, Ratcliffe is describing existence at the body-schema level in contrast to existence at the body-image level. So long as the body- schema functions properly, we feel at-home within the world; we feel that we belong. Yet following impairments at the body-schema level, our sense of belonging weakens. Ratcliffe claims that emotional state should be discussed in terms of the lived-body and characterized in terms of belonging to the world. To be in a certain mood is to be-in-the-world in a certain way (Heidegger, 1996), as Leder (1990) put it: “mood and emotions are world- disclosive” (p. 21). Thus, while emotions are for the most part object-oriented (e.g., I love X, I hate Z), moods are preintentional and in fact “determine the kinds of intentional states we are capable of adopting, amounting to a ‘shape’ that all experience takes on.” Moods are “ways of fnding oneself in-the-world” (Ratcliffe, 2015, p. 35). Furthermore, alterations in mood refect the sense of how we feel within the world. Indeed, when our mood changes, we experience the world differently (Jaspers, 1963). For instance, when we are in a depressed mood, our range of possibilities decreases and the pragmatic phenomenal feld representing the I-can shrinks, resulting in a feeling that almost anything is beyond our abilities: The phenomenal feld becomes an I-Can-Not kind of feld, and over time, we may become isolated from the world (Ratcliffe, 2015). Likewise, when one is sick, “the body that previously opened up 2 THE TWOFOLD STRUCTURE OF HUMAN BEINGS 25 the world now becomes unpleasantly object-like … the body becomes strangely foreign, like a defective tool” (Ratcliffe, 2008, p. 117). If moods are indeed ways of fnding oneself in-the-world, they can be described in terms of body-schema precisely because the phenomenologically hidden body-schema ties us to the world. With this in mind, we may then say that mood changes are rooted, at least to some degree, in modifcations at the body-schema level; therefore, any changes in mood may be refected in the feeling of being at-home within the world. In our context, it is important to stress out that mood changes can be expressed as bodily changes or as changes in-the-world, or both: “someone with a pervasive feeling of strangeness, of being dislodged from everyone and everything, might say ‘my body feels strange’, ‘the world seems strange’, ‘everyone looks strange’ or just ‘it feels strange’” (Ratcliffe, 2015, p. 63). Indeed, Ratcliffe (2008) contends that “feelings of the body and feelings towards objects in-the-world are two sides of the same coin” (p. 111, my emphasis). Hence, any alteration at the bodily level of experience is expressed in the experience of the actual world: “the patient does not complain of psychological changes but of changed bodily feelings and, at the same time, of the world being different.” In practice, “these seemingly distinct symptoms are … different ways of describing the same phenomenon” (p. 115). We continuously sense our body in the context of the world and the world in the context of our body. Therefore, “feelings of the body and feelings towards objects in-the-world are two sides of the same coin, although one side or the other will often occupy the experiential fore- ground” (p. 111) and any change in the sense of body is expressed in the perceived world and in the sense of belonging to the world. Thus, the body “constitutes a sense of belonging, a context within which all purposive activities are embedded.” In turn, “the increasingly conspicuous body is not just something that withdraws from a within-world activity; it is also a change in the sense of belonging” (p. 112). This sense of not-belonging to the world is likewise accompanied by impairments in the SBO, a principle which is fundamental to understanding the sense of not-being-in-the-world among posttraumatic survivors. * This chapter has laid the philosophical foundations for this project. The next chapter examines the cognitive discourse, focusing mainly on the fexibility of the SBO. In particular, it considers the question of what it feels like to lack a sense of body-ownership. 26 Y. ATARIA

References Cole, J. (2005). On the relation of the body image to sensation and its absence. In H. De Preester, & V. Knockaert (Eds.), Body image and body schema: Interdisciplinary perspectives on the body. Amsterdam and Philadelphia: John Benjamins. Cole, J., & Paillard, J. (1995). Living without touch and information about body position and movement. Studies on deafferented subjects. In J. L. Bermúdez, A. Marcel, & N. Eilan (Eds.), The body and the self (pp. 245–266). Cambridge, MA: The MIT Press. De Haan, S., & Fuchs, T. (2010). The ghost in the machine: Disembodiment in Schizophrenia—Two case studies. Psychopathology, 43, 327–333. https://doi. org/10.1159/000319402. Dorfman, E. (2014). Foundations of the everyday: Shock, deferral, repetition. London and New York: Rowman & Littlefeld International. Fanon, F. (1968). The wretched of the earth (C. Farrington, Trans.). New York: Grove Press. Fuchs, T., & Schlimme, J. E. (2009). Embodiment and psychopathology: A phenomenological perspective. Current Opinion in Psychiatry, 22(6), 570–575. https://doi.org/10.1097/yco.0b013e3283318e5c. Gallagher, S. (2005). How the body shapes the mind. New York: Oxford University Press. Gallagher, S., & Cole, J. (1995). Body schema and body image in a deafferented subject. Journal of Mind and Behavior, 16, 369–390. Gallagher, S., & Zahavi, D. (2014). Primal impression and enactive perception. In D. Lloy & V. Arstila (Eds.), Subjective Time: The Philosophy, Psychology, and Neuroscience of Temporality (pp. 83–99). Cambridge, MA: MIT Press. Gibson, J. (1979). The ecological approach to visual perception. Hillsdale, NJ: Lawrence Erlbaum. Giummarra, M. J., Gibson, S. J., Georgiou-Karistianis, N., & John, B. L. (2008). Mechanisms underlying embodiment, disembodiment and loss of embodiment. Neuroscience and Biobehavioral Reviews, 32(1), 143–160. https://doi.org/10.1016/j.neubiorev.2007.07.001. Heidegger, M. (1996). Being and time (J. Stambaugh, Trans.). Albany: New York Press. Jaspers, K. (1963). General psychopathology. Chicago: The University of Chicago Press. Leder, D. (1990). The absent body. Chicago: The University of Chicago Press. Merleau-Ponty, M. (1964). The primacy of perception (J. Edie, Ed.). Evanston: Northwestern University Press. Merleau-Ponty, M. (1968). The visible and the invisible (C. Lefort, Ed., & A. Lingis, Trans.). Evanston: Northwestern University Press. 2 THE TWOFOLD STRUCTURE OF HUMAN BEINGS 27

Merleau-Ponty, M. (2002). Phenomenology of perception (C. Smith, Trans.). London: Routledge and Kegan Paul. Noë, A. (2004). Action in perception. Cambridge: The MIT Press. O’Regan, K. J. (2010). Explaining what people say about sensory qualia. In N. Gangopadhyay, M. Madary, & F. Spicer (Eds.), Perception, action, and consciousness (pp. 31–50). Oxford: Oxford University Press. O’Regan, K. J., & Noë, A. (2001a). A sensorimotor account of vision and visual consciousness. Behavioral and Brain Sciences, 24(5), 939–1031. O’Regan, K. J., & Noë, A. (2001b). What it is like to see: A sensorimotor theory of perceptual experience. Synthese, 129(1), 79–103. O’Shaughnessy, B. (2000). Consciousness and the world. Oxford: Clarendon Press. Ratcliffe, M. (2008). Feelings of being. Oxford: Oxford University Press. Ratcliffe, M. (2015). Experiences of depression. Oxford: Oxford University Press. Ryle, G. (1949). The concept of mind. Chicago: The University of Chicago Press. Varela, F., Thompson, E., & Rosch, E. (1991). The embodied mind: Cognitive science and human experience. Cambridge: The MIT Press. CHAPTER 3

Ownership

3.1 ownership Versus Sense of Body-Ownership (SBO) In posing the following question—“our bodies themselves, are they simply ours, or are they us?” (p. 291)—James (1890) suggests that ownership and sense of body-ownership (SBO) may not be identical. Similarly, de Vignemont (2007) claims that the body is both what we are and what belongs to us. She further notes that “it may seem as if it was nonsensical to ask whether you are sure that this is your own body” (p. 427). On the level of ownership “this body is our own in the sense that we know it, not in the sense that we feel it” (de Vignemont, 2010, p. 83, my emphasis). In contrast, in the case of SBO, not only do we know that the body is our own but we actually feel this is so. The crucial difference between knowing that this is my body and feeling that this is my body can be defned in terms of the difference between ownership (knowing) and sense of ownership (feeling). The feeling of body-ownership is non-conceptual and is rooted within the most basic sensorimotor loops; thus, it clearly occurs at the body- schema level. The existence of a feeling of body-ownership requires an absence contradictions or inconsistencies on the action-efferent level of the sensorimotor loop. This applies to the most basic level of mere touch as well as the more complex levels that integrate information from various sources—for instance, matching between proprioception and visual feedback. Indeed, different kinds of bodily information must be synchronized to achieve a sense of ownership. As long as no conficts ensue,

© The Author(s) 2018 29 Y. Ataria, Body Disownership in Complex Posttraumatic Stress Disorder, https://doi.org/10.1057/978-1-349-95366-0_3 30 Y. ATARIA we feel that the body is our own.1 In our daily life, we experience these feeling of bodily ownership as a “diffuse feeling of a coherent, harmoni- ous ongoing fow of bodily experiences” (Synofzik, Vosgerau, & Newen, 2008, p. 420). Yet, the onset of conficts and contradictions at the action-efferent level result in a decline in our sense of body-ownership diminishes; the body ceases to be transparent and we begin to “experience our body parts as strange, peculiar or alien” (Synofzik et al., 2008, p. 420). SBO does not necessitate refection of any kind but rather is part of the pre-refective experience of being-in-the-world. Furthermore, SBO “does not require an explicit or observational consciousness of the body” but “may depend on a non-observational access that I have to my actions, an access that is most commonly associated with a frst- person relationship to myself” (Gallagher, 2005, p. 29). In contrast to the implicit feeling of body-ownership, the judgment of body-ownership is explicit. Based on our conceptual beliefs, previous experience, ability to control, and general knowledge, we determine that this body is our own. Judgment of body-ownership occurs at the body-image level.

3.2 sBO—Manipulations In phenomenological terms, one cannot experience a lack of SBO without having previously possessed some identifable sense of ownership. Accordingly, unless our default state is a strong, or at least positive,2 SBO, we cannot experience a decrease in SBO. Although de Vignemont notes that “the existence of a positive phenomenology of ownership is not obvious” (2007, p. 430), she nevertheless believes that “there is something it is like to experience parts of my body as my own, some kind of non-conceptual intuitive awareness of ownership” (2010, p. 84).

1 The wording of this sentence appears somewhat strange. Yet upon closer examination, the diffculty in writing about this topic teach us something new. There is the body that I know is mine and there is the body that I feel is mine. These are not the same thing. Even worse, the very wording used here is a transgression because there is no “I” to which this body does or does not belong. This is precisely the Cartesian error of circular reasoning. This is the reason that any discussion of the SBO is so problematic: It always touches upon and turns into dualistic thought, even though those investigating this topic attempt to transmit the exact opposite. 2 Later in the book, we will also see that an SBO which is too strong is similarly problematic. 3 OWNERSHIP 31

We can describe this in terms of “a positive phenomenology of ‘myness’” (p. 83). The rubber hand illusion (Botvinick & Cohen, 1998) and studies of amputees ftted with prosthetic limbs (Murray, 2004) can enhance our understanding of the positive phenomenology of “myness.” Let us begin with the rubber hand illusion.

3.2.1 The Rubber Hand Illusion The rubber hand illusion (RHI) is an experimental paradigm that enables us to simulate controlled manipulation of body-ownership. According to Tsakiris (2011), “the rubber hand is not simply added as a third limb, but instead it replaces the real hand, in terms of both phenomenal experience and physiological regulation” (p. 184). In brief, the experience of watching a rubber hand being stroked synchronously with our own unseen hand leads us to attribute the rubber hand to our own body, making us feel like it’s our hand (Botvinick & Cohen, 1998). We should note, however, that this manipulation occurs on the level of feeling (I nevertheless know which hand is really mine) and is based upon synchronization between two different sources of information: visual and tactile (Tsakiris & Haggard, 2005). This experiment demonstrates that SBO is not infuenced merely by bodily sensations but also by vision. More precisely, SBO is affected by synchronization between the tactile dimension and the visual dimension: “temporal asynchrony between vision of touch and felt touch will not induce the subjective referral of touch to the rubber hand and the even- tual feeling of body-ownership” (Tsakiris, 2011, p. 191). The RHI has fundamental implications: (a) the knowledge that this is my body and the feeling that this is my body are rooted in different kinds of mechanisms; (b) SBO cannot be reduced to mere physical boundaries; and (c) SBO can be manipulated, at least to some extent. The following examination of the use of prostheses sheds light on the phenomenology of SBO.

3.2.2 Prosthetic Limbs Prostheses are tools of sorts. Although intended to replace a missing limb, a prosthetic limb is nevertheless not exactly part of the body-as- object (Körper) because it is not made of the same stuff as our biological 32 Y. ATARIA body. Yet a prosthetic limb may become part of the lived-body. In fact, as studies reveal, an appropriate and well-controlled tool can become “an extension of the hand that wields it” (Maravita, Spence, & Driver, 2003, p. 536) and in some cases can even develop into a tool that is “strongly related to a feeling of nonmediation between the agent and the world” (De Preester & Tsakiris, 2009, p. 312). Indeed, a successful prosthesis should become non-existent. It should be experienced as though it were not there, as in the case of a blind man’s cane:

once the stick has become a familiar instrument, the world of feelable things recedes and now begins, not at the outer skin of the hand, but at the end of the stick… the stick is no longer an object perceived by the blind man, but an instrument with which he perceives. It is a bodily auxiliary, an extension of the bodily synthesis. (Merleau-Ponty, 2002, pp. 175–176)

A successful prosthesis should become an integral part of the body, in the same way that the original limb was part of the biological body. As such, it should be experientially transparent, a “knowing body-part… something that shares in the knowledge of the body” (De Preester & Tsakiris, 2009, p. 311, my emphasis). Yet a prosthetic hand is not simply another tool coded within the brain as though it were an extension of the arm. Although we can control tools, a strong sense of ownership does not extend to them. To be more precise, although tools may become embodied, SBO is not necessarily projected onto them (de Vignemont, 2010). Conversely, because a prosthetic limb must become an integral part of the knowing body, a strong SBO should be projected onto it, at least if it is well planned. In addition, we need to feel that we control the prosthesis. Yet sense of agency (SA), that is, the sense of controlling one’s own body, is not restricted to the body and can be extended to tools. We should be able to control a ham- mer, although it is less clear why we would need to own it. SBO demands a twofold body model: a long-term-body-model and a short-term-(online)-body-model (De Preester & Tsakiris, 2009). Replacing a hand with a rubber limb alters the short-term-body-model (STBM), yet such an exchange would be impossible unless the long- term-body-model (LTBM) functions as though the real hand were part of the original/fxed model from the outset. Based on the LTBM, we know that the hand should be explicitly situated in the phenomenal feld. 3 OWNERSHIP 33

Therefore, while an SBO is not strongly projected onto a tool, the rubber hand fts naturally into the LTBM and hence a strong SBO can emerge. Thus, there is apparently more than one level of body representa- tion3: (1) long-term-body-representation, which is stable and constant over time (top-down), and (2) online-representation (bottom-up), which is anchored in the current moment (synchronized). The online, bottom-up representation is much more easily manipulated than the long- term-body-representation, as is demonstrated by the phenomenology of the RHI. Indeed, during the RHI, subjects do not feel that they possess three hands; rather the rubber hand has replaced their “real” hand in the short-term-(online)-body-model (Moseley et al., 2008). A strong sense of ownership requires that the limb become experientially transparent. For this to occur, the limb must become fxed within the LTBM, precisely because the LTBM provides a sense of transparency at the body-schema level. In other words, unless a prosthesis fts naturally into the LTBM, it will never become transparent and consequently cannot be part of the I-as-subject, the lived-body. Using Murray’s (2004) terminology, such a prosthetic limb might be experienced as “mine” yet it would not turn out to be “me.” With this in mind, let us now examine a number of additional examples from Murray’s (2004) study of individuals ftted with prostheses. Murray asked his interviewees the following questions: “How much do you actually notice your artifcial leg on a day to day basis? In what ways are you reminded of it?” The prosthetic limb of one respondent, PW, appears integrated into his LTBM but has not become part of his lived-body.

I am aware of it [the prosthesis] when it’s in my way. When you move side- ways or circular, you have to make more effort to swing around your prosthesis. It feels unnatural, so you’re aware of it. That feeling [has] decreased over the years, so perhaps in some ways I’m less aware then. (quoted by Murray, 2004, p. 968, my emphasis)

3 This concept is problematic—for a detailed discussion, see Gallagher (2017). Yet, these maps cannot be ignored. Indeed talking in terms of “body maps” does not necessarily force us to adopt a representative approach. With this in mind, the phenomenological radical enactive-embodied (and so forth) approach should be treated with appropriate caution, although we are bodies within the world, it does not means that our body is not (at least to some degree) mapped onto the brain as well. 34 Y. ATARIA

PW is aware of his prosthesis. Indeed, the way he uses his prosthetic limb is not natural and requires some conscious effort, similar to the case of Ian Waterman (see previous chapter). Nonetheless, PW has not completely failed to develop a sense of ownership or an SA toward his prosthesis. Rather, he has gained a weak SA (e.g., he necessarily makes more effort to swing his leg around) as well as a weak sense of ownership (e.g., he is aware of it). Moreover, in phenomenological terms, if PW’s awareness of his prosthetic limb has really decreased over the years so that he is now less aware of his prosthetic limb, we may suggest that sense of ownership can change over time. This provides support for the argument that sense of ownership is fexible and is not a Yes/No mechanism. Unlike PW, another respondent, WR, feels much more comfortable and at-home using his prosthesis:

It is not an easy question to answer. I think about it, but after 27 years I often do not. Sure, every time I walk I think about it, but I don’t dwell or focus on it. And not too long ago I was lying in bed with my wife. I had removed my limb. We were eating some food I had cooked and I decided to get up and do the dishes. I reached over to take her plate, got up, and forgot I did not have my limb on. I fell on the foor, landing on the distal end of the stump. It was a very frightening thing. Scary. It hurt like hell, and I stayed off it for about a week. So I guess I have reached a point where I am capable of such foolish acts as that and forget my leg was not on. (WR quoted by Murray, 2004, p. 968, my emphasis)

The nuances in this testimony are signifcant. While WR thinks about his prosthetic limb, thinking and feeling are very different. In fact, WR’s account of how he forgot to attach his limb indicates that the prosthetic limb has become profoundly integrated into his LTBM and that he pro- jects a strong sense of ownership toward it. It has become part of who he is. The above anecdotes reveal that with respect to prosthetic limbs, sense of ownership is fexible. Thus, we can describe SBO precisely as it weakens. If a perfect prosthetic limb could be created, it would be impossible to describe a positive phenomenology of the sense of ownership toward because we become aware of SBO only as it decreases (or, as we will see later, when it is too strong). 3 OWNERSHIP 35

Thus, at least theoretically, as a prosthetic limb approaches perfec- tion, it is ceases to be Mine and becomes ME; or, more precisely, I4— that is, part of the knowing subject, part of the living-body. As a further respondent, GL, notes in: “Well, to me it’s as if, though I’ve not got my lower arm, it’s as though I’ve got it and it’s [the prosthesis] part of me now. It’s as though I’ve got two hands, two arms” (GL quoted by Murray, 2004, p. 970, my emphasis). Considering these examples, we can describe the sense of ME and MINE as part of a spectrum: Sense of ownership is stronger at the level of ME than it is at the level of MINE. GL’s prosthetic limb thus appears to have become an integral part of his knowing body. A comparison of GL’s testimony with that of JGY reveals the diff erence between experiencing a prosthetic limb as ME and experiencing it as MINE. Indeed, JGY states: “it is not actually part of my body’s fesh, it is still mine even though it’s a piece of plastic and metal” (JGY, quoted by Murray, 2004, p. 970, my emphasis). JGY does not feel that the plastic and metal prosthetic limb is ME. It has not become a perfect knowing limb, and it has not become part of the lived-body or the body- as-subject. Instead, JGY describes a sense of MINE that is clearly much weaker than that felt by GL, who states that the prosthetic limb is part of ME now. We can describe the sense of ME as a default SBO state in which the SBO is strong, yet not overly so. Therefore, at the ME level there is no question regarding ownership of body parts, while at the MINE level such a question may arise. At the level of ME, the body is almost invisible; it is disregarded in favor of the perceived object itself (Legrand, 2006, 2007). This does not suggest that, given the limitations of technology, a prosthetic limb can become completely transparent, but rather that it is as close as possible to being so. In DM’s words, “[the prosthesis] must ‘feel’ as close to not being there as possible” (DM quoted by Murray, 2004, p. 970) (Fig. 3.1).

4 Currently, the optimal outcome appears to be a sense of ME. Technological limitations prevent a prosthetic limb from functioning perfectly at the level of I, the level of the lived- body. Yet this limitation is merely technical in nature and with technological advances a prosthetic limb could potentially become part of the I—that is, the body-as-subject or the living-body. 36 Y. ATARIA

ME cy aren

ransp Mine but not Me T

Not Me and not Mine Sense of body-ownership

-- -

Fig. 3.1 Three levels of the sense of body-ownership. We can defne three levels of the sense of body-ownership: (1) Me—strong (yet, not too strong) sense of body-ownership; (2) Mine—weak sense of body-ownership; and (3) Not me and not mine—no sense of body-ownership (though not body-disownership). As the sense of body-ownership becomes stronger, the sense of transparency increases. However, the linear curve can be applied only within certain boundaries. In fact, when the sense of body-ownership becomes too strong, the sense of transparency weakens

3.3 lack of Sense of Ownership Toward the Entire Body Until now we have discussed the SBO, or more precisely its fexibility, in relation to a particular limb. The remainder of this chapter expands the discussion, applying it to the context of the entire body. Such an expansion, however, should not be taken for granted and requires critical thinking. Nevertheless, as Tsakiris (2011) states: “the necessary conditions for the experience of ownership over a body-part seem to be the same as the ones involved in the experience of ownership for full bodies.” He continues: “the available empirical fndings from the two domains suggest that very similar neurocognitive processes are involved independently for ownership of body-parts and bodies” (p. 191, my emphasis). 3 OWNERSHIP 37

3.3.1 Autoscopic Phenomena In cases of illusory reduplication, “human subjects experience a second own body or self in their environment” (Blanke, Arzy, & Landis, 2008, p. 429). Such phenomena are broadly defned as autoscopic. During such experiences, both sense of embodiment and SBO alter. In addition, subjects with psychiatric conditions such as schizophrenia, depression, anxiety, and dissociative disorders sometimes report these kinds of experiences. In general, there are three kinds or levels of autoscopic experiences: autoscopic hallucination (AH), heautoscopy, and out-of-body- experiences (OBEs). Let us examine them one by one (Fig. 3.2). During AH, “people experience seeing a double of themselves in extrapersonal space without the experience of leaving their body” (Blanke et al., 2008, p. 430). Unlike out-of-body-experiences, in AH the center of awareness remains inside the physical body. In addition, AH experiences are not disembodied. The following description provides a

Fig. 3.2 The phenomenology of autoscopic experiences. This fgure shows the phenomenology of autoscopic experiences as well as the brain mechanisms associated with this phenomenology. (Illustration taken from Lopez, Halje, & Blanke, (2008): https://shamelesslyatheist.fles.wordpress.com/2009/11/autoscopy.jpg) 38 Y. ATARIA representative example of this kind of experience: “It wasn’t hard to realize that it was I myself who was sitting there. I looked younger and fresher than I do now. My double smiled at me in a friendly way” (Blanke et al., 2008, p. 432, my emphasis). Thus, although the “ego” or the sense of self may be localized within the natural boundaries of the body, the sense of body has altered. The sense of the actual body is hollow and extremely light. Furthermore, the individual can feel a sense of detachment from the body. The autoscopic-illusionary body feels like a three-dimensional ghost. This fgure sometimes acts like a refection in the mirror while on other occasions it is quite autonomous, particularly when executing activities the individual considered performing. Most importantly, although an autoscopic-illusionary body can be perceived as a slightly smaller, gen- derless, older/younger self, it is nevertheless “felt to be one’s own double” (Brugger, Regard, & Landis, 1997, p. 22). The following testimony exemplifes this feeling.

I would sit at a table and have beside me or in front of me another ‘me’ sitting there and talking to me. That’s my double. I have the impression of seeing him materialise before me; generally he would tell me that I had mis- guided my life … I do hear him, it’s an auditory impression, it’s a sensation. He has the same voice as me, maybe a little bit younger, he indeed seems to be a little bit younger than me. At these moments, I would have the impression of being in a state of as if I were an unreal piece which does not belong to my home. At these moments I really do believe in the reality of the double. (translated within Brugger et al., 1997, p. 22, my emphasis)

On the autoscopic spectrum, heautoscopy can be positioned between autoscopic hallucination and out-of-body-experiences. Subjects with heautoscopy see “a double of themselves in extrapersonal space” (Blanke & Mohr, 2005, p. 186). However, “it is diffcult for the subject to decide whether he/she is disembodied or not and whether the self is localized within the physical body or in the autoscopic body” (Blanke et al., 2008, p. 432). One subject describes her experience as follows: “I am at both positions at the same time” (Blanke, Landis, Spinelli, & Seeck, 2004, p. 248). Essentially, “subjects with heautoscopy generally do not report clear disembodiment,” yet nevertheless they are quite often “unable to localize their self.” Thus, “in some patients with heautoscopy the self is localized either in the physical body, or in 3 OWNERSHIP 39 the autoscopic body, and sometimes even at multiple positions” (Blanke et al., 2008, p. 432, my emphasis). During out-of-body-experiences, “people seem to be awake and feel that their ‘self,’ or center of awareness, is located outside of the physical body and somewhat elevated” (Blanke et al., 2008, p. 430). Others suggest that OBE can be defned as a kind of disembodiment: “the experience that the subject of conscious experience is localized outside the person’s bodily borders” (Blanke & Metzinger, 2008, p. 9). The following description is typical of this kind of experience:

Suddenly it was as if he saw himself in the bed in front of him. He felt as if he were at the other end of the room, as if he were foating in space below the ceiling in the corner facing the bed from where he could observe his own body in the bed… he saw his own completely immobile body in the bed; the eyes were closed. (Blanke et al., 2008, p. 430, my emphasis)

A fundamental question, however, concerns whether, during an OBE, the physical body simply turns into another body in space, like someone else’s body or an object; from the illusory body’s perspective, are the physical and illusory bodies completely separate? To answer this, it could be useful to examine the delusional misidentifcation syndrome in which one fails to recognize oneself in the mirror, even mistakenly treating the refection as an imposter (Silva, Leong, & Weinstock, 1993).5 In this case, one cannot identify one’s body as one’s own and insists that the physical body does not feel familiar. For instance, the French writer Guy de Maupassant (1850–1893) describes the following experience:

Do you know that by staring for a long time at my own image refected in a mirror, I sometimes feel that I am losing the notion of who I am? In those moments, everything gets confused in my mind and I fnd it bizarre to see a

5 Indeed, a fundamental question, to which we have found no satisfactory answer in the scientifc literature, is whether these subjects felt within their body. There are, however, some possible hints. Given the considerable overlap between delusional misidentifcation syndrome and schizophrenia (Fleminger & Burns, 1993), and given what we know about the phenomenology of schizophrenic patients while observing themselves in the mirror, we may speculate that some of those with delusional misidentifcation syndrome also have defcits at the body-schema level and thus do not feel completely comfortable within their bodies. 40 Y. ATARIA

head that I no longer recognize. So it seems strange to be who I am, that is to say: someone. (Maupassant within Dieguez, 2013, p. 102, my emphasis)

According to Sacks (2012), not only was Maupassant unable to recognize himself in the mirror, he even tried to shake the hand of the fgure he saw in the mirror. We can now reformulate the question more accurately: Should an OBE be defned as an out-of-body-(as-object)-experience or rather as an out-of- MY-body-experience? For the sake of discussion, let us assume that an OBE can be defned as an out-of-body-(as-object)-experience, and not as an out-of-MY-body-experience. In response to the question, “who is this (physical) body?”, the illusory fgure would answer that it does not know—similarly to Maupassant’s answer when he encountered his refection in the mirror. In fact, even if the illusory fgure were asked directly, “is this so-called physical body yours?”, the fgure would prob ably answer “no… This physical body looks like me but I am neverthe less sure that it is not mine and has nothing to do with me. I feel at-home where I am now (illusory body).” Interestingly, empirical fndings from pathological cases indicate that this kind of answer is possible. For instance, Ramachandran gives the following example:

Arthur sometimes duplicated himself! The frst time this happened, I was showing Arthur pictures of himself from a family photo album and I pointed to a snapshot of him taken two years before the accident. ‘Whose picture is this?’ I asked. “That’s another Arthur,” he replied. “He looks just like me but it isn’t me”. (Ramachandran & Blakeslee, 1998, p. 172)

If, however, the illusory fgure were to reply, “I am not sure, but this physical body feels somewhat familiar,” or “it does not merely look familiar but feels familiar,” this would necessitate a complete reconsideration of what it means to undergo a full OBE. Namely, should we defne this experience as an out-of-body-(as-object)-experience or rather as an out- of-MY-body-experience? If the physical body does not merely look familiar but feels familiar, then the following question immediately ensues: Does SBO entirely disappear—on the levels of both knowing and feeling— during an OBE? This question can also be rephrased from the opposite perspective: Does a total lack of SBO necessarily lead to the feeling that the physical body is simply another object in space, like someone else’s body? Or, rather, even when SBO drops to zero, can we nevertheless identify the physical body as something familiar—not merely on the level of knowing? 3 OWNERSHIP 41

Blanke’s studies provide a range of subjective descriptions of OBEs. Yet these do not portray experiences of feeling detached from a body (e.g., the physical body)6 which is not the individual’s own body. Therefore, on some level at least, individuals retain the ability to identify their body as their own. Consequently, it is evidently necessary to reformulate the concept of an out-of-body-experience by redefning this phenomenon as an out-of-MY-body-experience.7

3.3.2 Minimal Phenomenal Selfhood (MPS) Based on the above three categories of autoscopic phenomena, Blanke and Metzinger (2008) propose the minimal phenomenal selfhood (MPS) model. The MPS can be envisioned as at least somewhat equivalent8 to the sense of embodiment, that is, to the “experience that the self is localized at the position of our body at a certain position in space” (Lopez et al., 2008, p. 150). Indeed, the MPS “is associated with global, fully embodied self-consciousness and is experienced as a single feature” (Blanke & Metzinger, 2008, p. 9, my emphasis). The central features of the MPS are: (a) identifcation with the body as a whole, that is, a sense of ownership of the entire body and not merely of individual body parts; (b) spatiotemporal self-location; and (c) a weak frst-person perspective (1PP) that serves merely as a geometrical feature of a perceptual reference point. Empirical evidence indicates that each of the elements in the MPS can be damaged independently; impairment

6 Some people undergo an OBE in which they “do not experience a body at all, describing themselves as ‘pure consciousness’” (Alvarado, 2000, p. 186). However, beyond the obvious fact that these descriptions are extremely vague, it seems that from the phenomenological perspective these experiences are not even in the same category as OBEs, in which some kind of a body exists; that is, a shift into another (virtual) body. Thus, it is not clear that these kinds of experience should be defned as autoscopic phenomena. However, if these individuals experience an autoscopic phenomenon, it should be defned as a new category of being outside the body without being located in a new body. 7 An interview I conducted with a ketamine user revealed that under the infuence of this drug one can develop very strong OBEs. However, I was unable to fnd suffcient evidence of this in scientifc literature (e.g., Curran & Morgan, 2000; Morgan et al., 2011; Pomarol- Clotet et al., 2006; Wilkins, Girard, & Cheyne, 2011) to determine whether this is really an out-of-body-experience and not an out-of-MY-body-experience. 8 I am fully aware that the MPS is not completely equivalent to embodiment. Nevertheless, the MPS seems to be a new way of defning the concept of embodiment, an overused concept that has therefore become hackneyed. 42 Y. ATARIA of one does not necessarily imply disruption of the others. For instance, recent neuroimaging studies have found that body-ownership on the one hand and self-location on the other are implemented in rather distinct neural substrates that are, respectively, located in the premotor cortex and the temporoparietal junction. Thus, according to Serino et al. (2013), “clinical evidence and new research conducted on the RHI support the stronger claim of a double dissociation” (p. 1244) between the individual’s sense of body-ownership and self-location. With this in mind, we can reformulate the question: Are we detached from our OWN body or rather from A BODY (as-object) that is no longer truly our own? In view of the above, this question becomes much more complicated. If we are detached from our OWN body, we can argue that the MPS has disregarded a primitive dimension of our being, one which in fact precedes the three conditions of sense of ownership, self-location, and weak 1PP. Indeed, it will be argued that ownership, location, and 1PP cannot exist on the same level. In a series of studies conducted by Ehrsson’s group (Guterstam & Ehrsson, 2012; Petkova & Ehrsson, 2008; Petkova, Khoshnevis, & Ehrsson, 2011) at the Brain, Body, and Self Laboratory in Sweden, researchers used techniques similar to those applied in the RHI experiment to create a full body illusion. In so doing, they attempted to manipulate SBO at the level of the entire body. The virtual reality environment was not limited to synchronizing the sense of sight. In addition, they attempted to synchronize the sense of touch, facilitating a touching-being touched structure projected toward the illusory body. The results of this experiment (Guterstam & Ehrsson, 2012) indicate that SBO toward the illusory body comes at the price of losing ownership of the real body, just as ownership of a rubber hand comes at the expense of losing ownership of one’s real hand.9 These results suggest that losing sense of ownership over one’s biological body can be defned as a sense of disownership toward that biological body. Note, however, that whereas Ehrsson’s group defnes body-disownership as lack of SBO, in this book the defnition of body-disownership is fundamentally different.10

9 This is an important insight, because the same mechanisms acting at the level of the individual organ also act, at least in principle, at the level of the entire body. 10 Chapter 4 argues that body-disownership is not identical to a lack of SBO, but rather extends above and beyond the SBO. 3 OWNERSHIP 43

Ehrsson’s experiments involved much stronger manipulations at the level of body-ownership than those of Blanke’s group. Indeed, in Ehrsson’s experiments participants lost their sense of ownership toward their body.11 Ehrsson’s group relied on the principle that “there is a direct linear relationship between the strength of ownership of a hand and the degree of anxiety experienced when the hand is being subjected to physical threats”. Based on this concept, they have suggested that “threats to the ‘new body’ evoked greater skin conductance responses than threats to the ‘old’ physical one during the illusory body swapping” (Petkova & Ehrsson, 2008, p. 6), indicating that sense of ownership has shifted to the new illusory body. Ehrsson’s group contend that “[f]irst person visual perspective is critical for triggering the illusion of full-body-ownership.” They further emphasize that “this is an important observation as it shows that the very basic sensation of owning one’s body is the result of a constructive process where visual, tactile, and proprioceptive signals are integrated in ego-centric coordinates” (Petkova et al., 2011, p. 5). A careful reading suggests that SBO is not the most basic element in this model. Rather, Ehrsson’s group propose that 1PP is a precondition for SBO. Whereas, according to the MPS, full embodiment requires three equal conditions (sense of ownership, self-location, and weak 1PP), the studies conducted at the Brain, Body, and Self Laboratory in Sweden contend that 1PP is not on the same level as SBO but rather a precondition for SBO. As a variety of studies demonstrate (Maselli & Slater, 2013; Kokkinara, Kilteni, Blom, & Slater, 2016), there is “clear evidence for 1PP being a critical factor for eliciting the full body-ownership illusion”. Moreover, it has been shown “that violation of 1PP over the fake body is suffcient to prevent the full body-ownership illusion.” In practice, the “frst person perspective is a necessary condition for the full body-ownership illusion” (Maselli & Slater, 2013, p. 10). Furthermore, some argue that “1PP seems to clearly dominate as an explanatory factor for subjective and physiological measures of ownership” (Kokkinara et al., 2016, p. 8).

11 One could argue that considering the different techniques employed in these experiments, it is impossible to compare the experiences described. Yet given the nature of our discussion here, this kind of objection is irrelevant. Furthermore, in suggesting a model for selfhood based on OBE and the like, Blanke and Metzinge (2008) are not overly concerned by the limitations of these kinds of experiences. Thus, they cannot object to comparisons with other setups that create similar manipulations using different kinds of techniques. 44 Y. ATARIA

At the very least, then, the MPS model must be updated, because sense of ownership and 1PP cannot be defned as two equal factors. Instead, we propose a vertical model in which SBO is based on 1PP. As a result, any damage at the 1PP level leads to the immediate collapse of SBO, while the opposite is not necessarily the case.

3.3.3 Total Lack of Sense of Ownership Toward the Entire Body The studies conducted by Ehrsson’s group indicate that an individual cannot own two bodies12 and that development of a strong sense of ownership toward a virtual body is necessarily at the expense of the biological body. Ehrsson’s studies apply techniques used in the case of RHI toward the whole body. In these studies, the virtual fgure develops a sense of touching-being touched, that is, a sense of ambiguity emerging from being both a subject and an object at the same time. During OBEs, in contrast, the virtual fgure does not develop a sense of touching-being touched and does not acquire a sense of ambiguity.13 Hence, we may argue that OBEs do not exemplify a total lack of SBO: Obviously in the case of OBEs, the SBO is stronger than it is in a virtual reality environment. Thus, OBEs are marked by a decrease in SBO rather than its total absence. To provide phenomenological descriptions of the total lack of SBO, we now examine the phenomenology of depersonalization and other related phenomena. According to the DSM-5 (American Psychiatric Association, 2013), when experiencing the dissociative disorder known as depersonalization, the individual feels detached from herself or the environment, in addition to feeling detached from her feelings, thoughts, or actions. Individuals who suffer from depersonalization as a psychiatric disorder no longer feel at-home within the world (Simeon & Abugel, 2006). Rather, they feel a sense of non-belonging (Ratcliffe, 2008). Given that depersonalization

12 This remark is not trivial, because in some cases patients feel that they have three hands. 13 The way in which these experiences are conducted is undoubtedly of crucial importance. Despite the criticism in this chapter, we are certainly aware of the methodological limitations of each of the methods described for producing OBEs. 3 OWNERSHIP 45 involves problems at the level of body-schema,14 this sense of non- belonging is unsurprising. Depersonalization is sometimes accompanied by autoscopic experiences (e.g., autoscopic hallucination, heautoscopy, and OBE), all of which share at least one feature: a decline in SBO. More precisely, depersonalization and autoscopic experiences are located on the same spectrum. Yet, unlike out-of-MY-body-experiences, in extreme cases of depersonalization the sense of ownership practically disappears, to the extent that individuals cease to recognize their own body, at least not at the level of body-as-subject. Such extreme cases share characteristics with the Cotard delusion—a rare mental illness marked by development of a strong belief that one is dead or has ceased to exist, thus the body becomes object-like:

A depersonalization phenomenon was reported as an essential step in the development of Cotard’s syndrome… Depersonalization may occur when Körper prevails over Leib and when the body is less associated with the self (Leib). However, in depersonalization the patient feels like being dead (indifference of affect), while in Cotard’s syndrome the patient is convinced to be dead (lack of feeling). (Debruyne, Portzky, Peremans, & Audenaert, 2011, p. 69, my emphasis)

In this context, we can now begin examining situations in which individuals are detached not only from their own body but also from the body-as-object. In such situations, subjects lose all contact with their body and, as a result, their experience becomes an out-of-body-(as-object)-experience. The separation in such a case is so radical that the individual’s SBO totally collapses. At this point of extreme and fundamental impairments in functioning at the body-schema level, individuals cease to feel their selves from within. The body-as-subject or the lived-body stops

14 A PET study of eight subjects suffering from depersonalization disorder suggests that individuals with this disorder have developed body-schema disturbances. In fact, the researchers in this study suggest that “body-schema distortions characteristic of depersonalization might be more subtle, functionally based, less neurologically damaged versions of well-known parietal lobe neurological syndromes such as neglect, fnger agnosia, and hemidepersonalization” (Simeon et al., 2000, p. 1786). In turn, the fndings of this study suggest abnormalities “in areas responsible for an integrated body-schema” (Simeon et al., 2000, p. 1787). For a short review, see Dieguez and Lopez (2017). 46 Y. ATARIA functioning, and the body-as-object becomes the center of the experience. The question, then, is whether such individuals also strongly believe that this body is not their own, even if they know it is their body. Examining a condition known as negative heautoscopy can help to clarify this point. Negative heautoscopy can be defned “as the failure to see one’s own body either when looked at directly or in a mirror” (Blanke et al., 2008, p. 451). On the cognitive level, the experience of seeing oneself in the mirror is extremely important. While we can examine our body by manipulating a number of mirrors in various ways, we still cannot feel the mirror image of our body from the inside. The fgure in the mirror cannot gain 1PP. To achieve a 1PP, we would need another body—a viewpoint that is totally external to our body. This is, of course, impossible, because our body is always with us. Thus, even if we could adopt a totally different point of view, it would be the perspective of another body in which we would be imprisoned, leaving the problem unsolved. We would require a third body to gain perspective, and so on ad infnitum. Even when looking at ourselves in the mirror, we are not just “another object” because we always look in the mirror and at ourselves from within our body. It is indeed true that in some (occurred) cases, while looking in the mirror from within, we can become alienated from the image we encounter. Yet, as we know from our daily experience, this separation is almost never absolute: The observing image and the refected image are always synchronized: “My body in the mirror never stops following my intentions like their shadow” (Merleau-Ponty, p. 105). The image in the mirror is an intermediate entity enabling us to understand how others and the world see us. And yet, the separation between ourselves and our mirror image remains partial. Indeed, we can never adopt the point of view of the refected image. With the exception of some severe psychiatric cases,15 the fgure in the mirror will never be the source of motion. Furthermore, when we reach out to touch the mirror, we feel the frightening coldness of the real object. We cannot touch the fgure

15 In this context, let us take a look at the following example of a patient whose body schema has broken down: “When I am looking into a mirror, I do not know any more whether I am here looking at me there in the mirror, or whether I am there in the mirror looking at me here…. If I look at someone else in the mirror, I am not able to distinguish him from myself any more” (Kimura, 1994, p. 194 within Fuchs, 2005, p. 104) 3 OWNERSHIP 47 refected in the mirror because the mirror does not really enable us to leave our body and experience it from a third-person perspective (3PP). The mirror is a way for the eye to touch itself or for us, as a complete unit, to touch ourselves as a whole. In effect, the experience of looking in the mirror is no different from the experience of touching our left hand with our right hand. When we touch our left hand with our right hand, the right hand is the touching subject and the left hand is the object being touched. Even while looking in the mirror, we retain our unique dual nature of being object and subject simultaneously: “when I try to fll this void by recourse to the image in the mirror, it refers me back to an original of the body which is not out there among things, but in my own prov- ince, on this side of all things seen. It is no different, in spite of what may appear to be the case, with my tactile body, for if I can, with my left hand, feel my right hand as it touches an object, the right hand as an object is not the right hand as it touches” (Merleau-Ponty, 2002, p. 105). Let us now compare the phenomenology of OBE to that of negative heautoscopy. Maselli and Slater (2013) argue that “self-identifcation during OBEs is not an actual perceptual illusion, but rather a form of self-recognition similar to the self-recognition of oneself in a mirror” (p. 3, my emphasis). If this is indeed the case, during OBEs the individual retains the dual structure of being simultaneously subject and object. Indeed, an OBE is simply a strengthened version of this inherent structure. In contrast, negative heautoscopy, a condition in which the individual seems to deny the existence of the body totally, and the Cotard delusion, in which one develops a strong belief that one is dead or has ceased to exist, represent the collapse of this structure. Negative heautoscopy is typically accompanied by depersonalization and loss of body awareness (Brugger et al., 1997). Those who experience negative heautoscopy are not infuenced by the fact that they can see a body, which is of course their own, in the mirror. Despite perhaps knowing that they have a body, they strongly deny its existence or else claim that the body they see is not their own. In contrast, even in cases of depersonalization marked by a strong drop in the SBO, it is unclear whether individuals actually believe the body they see in the mirror is not their own. In extreme cases, however, depersonalization is very close to the feeling of no longer being able to recognize the body as their own. Thus, we suggest that severe cases of depersonalization represent a state in which individuals totally lack SBO and do not recognize their body as their own. This condition is usually accompanied by negative heautoscopy (Figs. 3.3 and 3.4). 48 Y. ATARIA

Sense Experience of unreal world (partial detachment) of

bo A dy -o wn B

er OBE

sh Everyday ip experience Depersonalization

D Cotard's delusion - total lack of sense of body-ownership

Dissociation (Body-as-Subject/Body-as-Object)

Fig. 3.3 Flexibility of the sense of body-ownership. Schematic and simplifed (though not necessarily linear, as in this representation) presentation of the relationship between a weakening sense of ownership and a sense of dissociation from the world (ratio between body-as-subject and body-as-object see Fig. 3.4). This graph demonstrates the change from everyday experience (A) to the experience of an “unreal” world (B), to OBE (C), to depersonalization (D) and fnally to a total lack of sense of body-ownership (E). At point A, there is a certain balance between the body-as-subject and the body-as-object. Moving towards point E, this balance tips towards the body-as-object, and fnally the body-as-object becomes the center of the experience, where the individual exists at the level of body-image

(a) (b) Body-as- object Body-as- Body-as- subject object Body-as- subject

Fig. 3.4 Body-as-subject vs. body-as-object. Points A–D on the curve in Fig. 3.3 represent a change in the equilibrium between the body-as-subject and the body-as- object, as described in a. Point E on the curve in Fig. 3.3 represents the collapse of the dual structure (being at once both subject and object), as described in b 3 OWNERSHIP 49

3.4 sBO—Main Insights The RHI led to the creation of a new paradigm—manipulation of the SBO. The last two decades have witnessed an explosion of studies in this feld, not merely with respect to limbs but rather on the level of the whole body. Based on the analysis presented in this chapter, we contend that SBO is:

1. Activated at the body-schema level; 2. Flexible, yet a lack of SBO cannot be defned as an OBE because during an OBE we continue to identify the body as our own, at least to some extent; 3. Not identical to embodiment, although impairments on the level of SBO will cause some disturbances on the level of sense of embodiment; 4. Not independent of 1PP. Thus, SBO is rooted in the 1PP. Impairments on the level of 1PP will cause disturbances on the level of SBO, yet the opposite is not the case; 5. Not restricted to the boundaries of the body. SBO can extend to a prosthesis (which is part of the long-term body map) and to other tools (usually through SA); and 6. Unable to be split into two different entities.

This chapter has discussed the SBO in great detail. Nevertheless, an examination of this mechanism independent of the sense of agency (SA)—the sense of controlling the body—is quite artifcial. Indeed, in our daily lives these cognitive mechanisms go hand in hand. The next chapter describes the complex relationship between the SBO and SA.

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Petkova, V. I., & Ehrsson, H. H. (2008). If I were you: Perceptual illusion of body swapping. PLoS One, 3(12), 1–9. https://doi.org/10.1371/journal. pone.0003832. Petkova, V. I., Khoshnevis, M., & Ehrsson, H. H. (2011). The perspective matters! Multisensory integration in ego-centric reference frames deter- mines full-body ownership. Frontiers in Psychology, 2(35), 1–7. https://doi. org/10.3389/fpsyg.2011.00035. Pomarol-Clotet, E., Honey, G. D., Murray, G. K., Corlett, P. R., Absalom, A. R., Lee, M., … Fletcher, P. C. (2006). Psychological effects of ketamine in healthy volunteers. The British Journal of Psychiatry, 189(2), 173–179. https://doi.org/10.1192/bjp.bp.105.015263. Ramachandran, V. S., & Blakeslee, S. (1998). Phantoms in the brain. New York: Quill William Morrow. Ratcliffe, M. (2008). Feelings of being. Oxford: Oxford University Press. Sacks, O. (2012). Hallucinations. New York: Alfred A. Knopf. Serino, A., Alsmith, A., Costantini, M., Mandrigin, A., Tajadura-Jimenez, A., & Lopez, C. (2013). Bodily ownership and self-location: Components of bodily self-consciousness. Consciousness and Cognition, 22(4), 1239–1252. https:// doi.org/10.1016/j.concog.2013.08.013. Silva, J. A., Leong, G. B., & Weinstock, R. (1993). Delusions of transformation of the self. Psychopathology, 26(3–4), 181–188. Simeon, D., & Abugel, J. (2006). Feeling unreal: Depersonalization disorder and the loss of the self. Oxford: Oxford University Press. Simeon, D., Guralnik, O., Hazlett, E., Spiegel-Cohen, J., Hollander, E., & Buchsbaum, M. (2000). Feeling unreal: A PET study of depersonalization disorder. The American Journal of Psychiatry, 157(11), 1782–1788. Synofzik, M., Vosgerau, G., & Newen, A. (2008). I move, therefore I am: A new theoretical framework to investigate agency and ownership. Consciousness and Cognition, 17(2), 411–424. https://doi.org/10.1016/j. concog.2008.03.008. Tsakiris, M. (2011). The sense of body ownership. In S. Gallagher (Ed.), The Oxford handbook of the self (pp. 180–203). Oxford: Oxford University Press. Tsakiris, M., & Haggard, P. (2005). The rubber hand illusion revisited: Visuotactile integration and self-attribution. Journal of Experimental Psychology: Human Perception and Performance, 31(1), 80–91. Wilkins, L. K., Girard, T. A., & Cheyne, J. A. (2011). Ketamine as a primary predictor of out-of-body experiences associated with multiple substance use. Consciousness and Cognition, 20(3), 943–950. https://doi.org/10.1016/j. concog.2011.01.005. CHAPTER 4

When Ownership and Agency Collide: The Phenomenology of Limb-Disownership

4.1 sense of Agency Sense of agency (SA) can be defned intuitively as “the sense that I am the one who is causing or generating an action” (Gallagher, 2000, p. 15). More precisely, “if someone or something causes something to happen, that person or thing is not an agent (even if they might be a cause) if they do not know in some way that they have caused it to happen” (Gallagher, 2007, p. 347, my emphasis). Whereas SA is usually described “as frst-order experience linked to bodily movement” (Gallagher, 2007, p. 355), some suggest that this sense is not restricted to bodily movements but also includes the ability to control thoughts (Frith, Blakemore, & Wolpert, 2000; Gallagher, 2000). Most scholars tend to defne SA on the intentional level because a strong sense of control is necessary for an SA to emerge. We must be aware of our goals and intentions, beliefs, desires, and so on and be able to connect between our actions and conscious intentions (Farrer et al., 2003). Yet as Tsakiris and Haggard (2005) argue, SA is directly connected to motor control and efference signals. Namely, SA does not require us to be explicitly aware, at least not in any strong sense, of our goals and intentions and thus “could be simply a matter of a very thin phenomenal awareness, and in most cases it is just that” (Gallagher, 2007, p. 347). Indeed, actions can also be controlled in a weak sense: “We do not attend to our bodily movements in most actions. We do not stare at our own hands as we decide to use them; we do not look at our

© The Author(s) 2018 53 Y. Ataria, Body Disownership in Complex Posttraumatic Stress Disorder, https://doi.org/10.1057/978-1-349-95366-0_4 54 Y. ATARIA feet as we walk, we do not attend to our arm movements as we engage the joystick.” In fact, “most of motor control and body schematic processes are non-conscious and automatic” (Gallagher & Zahavi, 2008, p. 165). These non-conscious and automatic processes occur at the body- schema level. An examination of everyday actions serves to illustrate this notion further. For example, as we type on a keyboard we do not feel a desire to move our fngers. Rather, something in us, not even words but merely abstract thoughts, struggles to fnd its way out through our fngers. However, if we attempt to type the same sentence using the DVORAK Simplifed Keyboard rather than the QWERTY keyboard, we would fnd ourselves struggling with our own fngers because they would no longer function on automatic pilot. This “struggle” represents a explicit sense of control, while our fngers typing on automatic pilot on the QWERTY keyboard are implicitly controlled through the SA at the body-schema level. This distinction explains Gallagher’s (2011) claim that one does not need a strong sense of control over one’s actions to possess an SA. Rather, SA is a pre-refective experience and hence almost invisible. In short, as long as SA is not lacking, it continues to exist with minimal self-awareness. Motor control processes at the body-schema level generate this pre-refective SA. In fact, as in the case of the sense of body-ownership (SBO), only when we lose control over our actions do we become aware that we lack an SA. For example, while walking we implicitly possess an SA. Yet when someone pushes us, we feel that we are being pushed and realize that this particular movement is not something we willingly chose. Our SA remained implicit until the moment we were pushed. At that juncture, the SA was disturbed and its absence became explicit, making us implicitly aware of the moment at which voluntary action was transformed into involuntary action. Note, however, that the SBO is not lost in the process. Another distinction useful in this context is the disparity between the feeling of agency and the judgment of agency (Synofzik, Vosgerau, & Newen, 2008). Feeling of agency is non-conceptual and implicit, emerging at the body-schema level. It is a basic and weak feeling of self/ non-self action causation. Judgment of agency, by contrast, requires an interpretative judgment of being the agent based on conceptual framing 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 55 of the situation and one’s beliefs. Judgment of agency requires strong expectations regarding the result of actions based on previous history and knowledge of the world in terms of causality, logic, and so on, and it emerges at the level of body-image.

4.2 ownership vs. Agency: Double Dissociation Some researchers suggest that SA and sense of ownership are not marked by the same phenomenology and are rooted in different types of cognitive mechanisms (Gallagher, 2000; Synofzik et al., 2008; Tsakiris, Longo, & Haggard, 2010). Sato and Yasuda (2005) note that SA and sense of ownership may “be partly independent” and “have different processes by which each of them is constructed” (Sato & Yasuda, 2005, p. 253). Thus, although in everyday life we usually experience the senses of ownership and agency as intimately coupled, they are nevertheless marked by a double dissociation. Indeed, not only do we suggest that feelings of ownership and feelings of agency may be dissociated on a theoretical level, but that in fact “these sensations represent independent processes of the human brain” (Kalckert & Ehrsson, 2012, p. 9).1 Nevertheless, totally isolating the SBO from the SA would be a fundamental mistake. Indeed, even though the SA can be extended to external tools, “participants reported signifcantly stronger agency when the model hand was perceived as part of one’s body than when it was perceived to be an external object.” Hence, some suggest that “the experience of body agency is more closely linked to the feeling of body-ownership than to external agency” (p. 11). Furthermore, when an external tool is controlled actively, the sense of ownership extended

1 Body-ownership has been linked to processing in several regions. These include the premotor cortex (PMC), intraparietal cortex (IPC), temporoparietal junction (TPJ), sensorimotor cortex, extrastriate body area (EBA), and insula (Arzy, Thut, Mohr, Michel, & Blanke, 2006; Blanke, 2012; Tsakiris, Hesse, Boy, Haggard, & Fink, 2006). The processing of interoceptive information occurs on well-defned pathways from the dorsal root of spinal nerves to the thalamus, nucleus of the solitary tract. This is then relayed to the central cortical processing regions of the anterior cingulate cortex (ACC) and insular cortex (Craig, 2003; Critchley & Harrison, 2013). Essentially, although neural processing connected to agency, ownership and interoception are subserved by distinct brain systems, they show some partial convergence in the insular and medial frontal regions. 56 Y. ATARIA toward this tool becomes stronger. Interestingly, however, “even in the absence of an engaged agency mechanism, the presence of ownership still drives a residual SA.” This phenomenon can be explained as a “general tendency to ascribe agency to an owned body part” (p. 12). Indeed, in our daily life SA and SBO go hand in hand. Having said this, let us examine more closely two contrasting phenomena—agency without ownership and ownership without agency—by means of the alien hand and the anarchic hand syndromes. Scientifc literature sometimes confuses anarchic hand syndrome with alien hand syndrome, defning both as alien hand syndrome. Yet Marchetti and Sala (1998) emphasize that anarchic hand syndrome “should be differentiated from the feeling of nonbelonging of a hand” (p. 191), which is defned as the alien hand (lack of sense of ownership). In the case of alien hand syndrome, patients do not display involuntary movement yet at the same time feel that their hand has become a foreign limb. In the context of this book, it is signifcant that those reporting these strange feelings do not deny their ability to control the bizarre hand which is no longer their own. The anarchic hand syndrome is a mirror image of the alien hand syndrome. In the case of anarchic hand syndrome, individuals lose the ability to control a hand they experience as their own. Furthermore, these two syndromes are caused by lesions in different regions of the brain. Let us examine these phenomena one by one.

SBO SA Anarchic hand + − Alien hand + − The anarchic hand phenomenon occurs at the level of the SA but not at the level of the sense of ownership. Those experiencing this phenomenon report that the errant hand moves against their will and they are unable to resist its movements (Marchetti & Sala, 1998). Anarchic hand syndrome is accompanied by a sense that the errant hand possesses a different personality, as demonstrated by comments such as “it doesn’t want to stop” or “I can’t make it listen to me.” Quite amazingly, the errant hand continues to move involuntarily during sleep (Banks et al., 1989). In some cases, patients may even 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 57 slap the errant hand with the so-called “good” hand. These subjects tend to deny that a psychiatric disorder is responsible for the disturbance. In fact, while some are unaware of their involuntary goal-directed actions, others simply deny the existence of any problem (Leiguarda, Starkstein, & Berthier, 1989). Yet, those suffering from anarchic hand syndrome are fully aware of the discrepancy between what they want their hand to do and what it actually does (Kritikos, Breen, & Mattingley, 2005). Specifcally, even if they deny having any kind of problem, analysis of their movements reveals they are nevertheless unconsciously aware of it (Biran, Giovannetti, Buxbaum, & Chatterjee, 2006). In extreme cases, patients with anarchic hand syndrome have woken up to fnd their errant hand choking them (Banks et al., 1989). In other bizarre situations, the errant hand acts in opposition to the “good” hand. For instance, Bogen (1993) reports a patient whose errant hand opened the buttons of his shirt while his “healthy” hand tried to close them. Similarly, Biran et al. (2006) record the case of JC, a 56-year- old right-handed man who suffered a left hemispheric stroke and presented initially with mild right-sided weakness and naming diffculties. In some situations, JC’s right hand “acted at cross-purposes to the left hand,” so that “sometimes it would interfere with the left hand while it was performing actions” (p. 567). JC’s errant hand was basically hostile. According to his wife, JC’s right (errant) hand acted like a “toddler in a bad mood” (p. 568). Essentially, JC’s errant hand did not merely function automatically without purpose but rather demonstrated “organized purposeful behaviour” (p. 577). Simply put, JC’s errant hand “wants to be the boss” (p. 567). As noted above, in terms of the relation between SA and SBO, the alien hand syndrome is the mirror image of the anarchic hand syndrome. Indeed, Della Sala et al. stress that Brion and Jedynak’s original study (1972) does not describe the alien hand syndrome in terms of SA but rather solely in terms of SBO:

The patient who holds his hands one within the other behind his back does not recognise the left hand as his own… The sign does not consist in the lack of tactile recognition of the hand as such, but in the lack of 58 Y. ATARIA

recognition of the hand as one’s own. (Brion & Jedynak, 1972, p. 262, translated within Della Sala, Marchetti, & Spinnler, 1994, p. 192, my emphasis)

With this in mind it has been suggested that we should restrict use of the term “alien hand” to a sense that one’s hand is no longer recognized as one’s own—agency without ownership. Thus, this term “should be used solely in connection with the hemisomatognosic-like symptom of the lack of recognition of one’s own hand, linked to more posterior lesions” (Della Sala et al., 1994, p. 200).

4.3 towards a Theory of Limb-Disownership Although SBO and SA are not rooted in the same mechanism, they are nevertheless not totally independent. Indeed, in our daily life these mechanisms go hand in hand. Yet as shown in the above descriptions of the anarchic hand and the alien hand syndromes, they can become detached and may even confict with one another. When SBO and SA clash, strange feelings of different kinds emerge. This clash constitutes the essence of limb-disownership. The remainder of this chapter seeks to provide a cognitive explanation for limb-disownership through a detailed examination of somatoparaphrenia and body integrity identity disorder (BIID), both of which are defned in scientifc literature as forms of disownership (de Vignemont, 2010). Somatoparaphrenia is described as a “delusion of disownership of left-sided body parts” (Vallar & Ronchi, 2009, p. 533), characterized by ownership without agency, as in the anarchic hand syndrome. BIID, in opposition, is defned as the desire to dispose of a body part; it is more similar to agency without ownership, as seen in the alien hand syndrome. We contend that limb-disownership emerges from a twofold mismatch, frst between SBO and SA at the body-schema level and then between body- schema and body-image.

Short description Relation between SBO and SA Somatoparaphrenia Delusion of disownership of left- Ownership without agency sided body parts BIID Desire to dispose of a body part Agency without ownership 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 59

4.3.1 Somatoparaphrenia2 Somatoparaphrenia is an uncommon yet not inconsequential symptom that can develop after damage to the right brain, usually following an acute stroke. This delusion is often, though not always, accompanied by left-sided paralysis and a denial or lack of awareness of that paralysis, known as anosognosia.3 Scholars have not yet determined “whether paralysis, or anosognosia, or both, are necessary for somatoparaphrenia to occur” (Rahmanovic, Barnier, Cox, Langdon, & Coltheart, 2012, p. 37). Thus, anosognosia for hemiplegia (the apparent unawareness of one’s contralesional motor defcit) does not necessarily go hand in hand with somatoparaphrenia. Indeed, some claim that the frequent co-occurrence of anosognosia for hemiplegia and somatoparaphrenia is most likely “due to the limited specifcity of naturally occurring brain lesions, rather than to a commonality of their central cognitive causal mechanisms” (Feinberg, Venneri, Simone, Fan, & Northoff, 2010, pp. 146–147). In most reported cases of patients with somatoparaphrenia, damage is detected at the proprioceptive level. These fndings lead Vallar and Ronchi (2009) to suggest that the phenomenon represents body- schema defcits. However, delusional disownership can extend to acces- sory objects associated with the affected limb, such as a wedding ring, apparently indicating that sensorimotor defcits alone cannot explain body-disownership. Some even suggest that “somatoparaphrenia is not simply a consequence of primary sensorimotor defcits, but a specifc failure in the linkage between primary sensorimotor experience and the self” (Fotopoulou et al., 2011, p. 3947). This explanation, however, is far from satisfactory. Indeed, a careful reading of this quotation questions what exactly Fotopoulou and her colleagues mean by “the self.” Clearly, a much deeper explanation is required.

4.3.1.1 Somatoparaphrenia—Beyond a Lack of SBO Somatoparaphrenia can be defned in terms of neglect on both the visual and the sensorimotor levels. The neglected limb or, in more severe cases, half of the body is experienced as heavy, dead, or lifeless

2 For an in-depth analysis of a number of cases, see Appendix 2. 3 Denial and lack of awareness are not equivalent phenomena or mechanisms. 60 Y. ATARIA

(Vallar & Ronchi, 2009). Nineteen months after his right hemorrhagic stroke, GA—who also suffers from left hemiplegia, severe left spatial neglect, disownership of his left limbs, and somatoparaphrenic symptoms along with anosognosia for motor disorders—offered the following description: “it is a dead hand… not a hand, it is an armrest… this arm is not mine… this arm and hand are dead” (Cogliano, Crisci, Conson, Grossi, & Trojano, 2012, p. 765). GA describes his experience in terms of it’s not mine, expanding his description by employing terminology such as dead hand. While the frst phrase (e.g., it’s not mine) appears a typical example of a total lack of SBO, the second phrase reveals that GA’s hand has lost the quality of being alive. More precisely, the dead hand is no longer both subject and object. It is no longer a tool like the blind man’s cane, allowing GA to perceive the world, but rather a thing, an object that cannot touch or be touched. Note that these feelings are not infuenced by GA’s knowledge about his (so-called) dead hand. His description seems to reveal a twofold typological structure or hierarchy: (1) The experience that it is not my hand represents a more basic mechanism at the level of ownership or some other cognitive mechanism, as we will see subsequently, while (2) the sense that it is a dead hand may represent GA’s interpretation of loss of ownership or alternatively his inter- pretations of some other basic cognitive injury or even a combination of defcits in more than one cognitive mechanism. Patients experiencing somatoparaphrenia do not merely deny that the affected limb or body half is their own. Rather, this experience can result in a “variety of aggressive behaviors (verbal, motor, or both) exhibited by hemiplegic patients towards the affected side” (Vallar & Ronchi, 2009, p. 534). Somatoparaphrenic symptoms, even when accompanied by anosognosia, result in a desire to dispose of the affected limb. For instance, AC, a 74-year-old right-handed man who suffered a left ischemic stroke, developed somatoparaphrenic symptoms along with anosognosia for motor disorders on the right side. Seven months after his stroke, AC sought to dispose of his hand. His motivation for so doing is straight- forward: “Because it does as it likes. It is sick. I would very much like to throw it away” (Cogliano et al., 2012, p. 766, my emphasis). In cognitive terms, AC’s frustration results from defcits at the SA level. AC’s experience can improve our understanding of the phenomenological disparity between a lack of SBO and body-disownership. Body-disownership, unlike lack of ownership, is usually accompanied by feelings such as I would very much like to throw it away. In addition, 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 61 at least in AC’s case, disownership can develop due to a loss of control. Thus, body-disownership is not equivalent to lack of SBO.4 Scientifc literature does not defne somatoparaphrenia in terms of lack of sense of ownership but rather in terms of disownership. Thus, not only do more than two-thirds of the patients with this condition experience a delusional belief that parts of their body do not belong to them, but they may also feel that these body parts belong to another person and in turn misidentify the limbs of another person as their own (Vallar & Ronchi, 2009). Indeed, in many cases the patient strongly believes that the hand belongs to the doctor: “Your (the doctor’s) hand” says one of them (Feinberg et al., 2010). Some argue (Davies, Coltheart, Langdon, & Breen, 2002) that patients with somatoparaphrenia typically attribute ownership of the paralyzed limb to others because they undergo the unusual experience of not being able to move their arm on command, indicating a loss of SA. A deeper analysis, however, suggests that these patients in fact do not accept that their hand is paralyzed and thus deny the loss of SA. If this is indeed the case, somatoparaphrenia involves SA and not merely SBO. Thus, we can even suggest that a lack of SA at the body-schema level, combined with denial of this lack of agency at the body-image level, can result in body-disownership. Furthermore, we can argue that body-disownership can develop over and above SBO, implying that ownership and disownership are not rooted in the same mechanism. We can even suggest that, at least in some cases, SBO must be present for the development of body-disownership because body-disownership results from a combination of (a) some positive SBO together with, (b) lack of SA, and (c) denial of this lack of SA. While (a) and (b) occur at the body-schema level, (c) occurs at the body-image level. Unlike the alien hand or anarchic hand syndromes, somatoparaphrenia cannot be reduced to or explained merely as a sense of estrangement of the affected body parts; rather, it is strongly associated with a solid belief that the affected body part is not one’s own. In extreme cases, the individual may even believe the affected hand belongs to someone else and thus fnds it unbearable to live with the disowned limb. Thus, in the words of GH—a 41-year-old man who developed somatoparaphrenia following a right temporoparietal stroke—it is impossible to ignore

4 What Guterstam and Ehrsson defne (2012) as body-disownership (see the detailed discussion in Chapter 3) is in fact the lack of sense of body-ownership. 62 Y. ATARIA the disowned limb: “It was very diffcult to begin with… to live with a foot that isn’t yours… It’s always there, always present…” (Halligan, Marshall, & Wade, 1995, p. 176, my emphasis). GH’s experience of always present is fundamental to understanding the nature of disownership. Indeed, it leads us to consider the possibility that body- disownership can be an outcome of the body’s over-presence. Namely, when SBO is too strong, the result is body-disownership. GH’s testimony supports the notion that body-disownership can result when an individual strongly denies the lack of SA, over and above SBO. In fact, if the SBO remains intact, one would feel that the affected hand is one’s own. Losing control over one’s own hand is responsible for the sense of over-presence, leading to a sense of limb-disownership. Indeed, if one has lost the ability to control one’s own hand, an unbearable paradox may develop: I cannot control my own hand under any circumstances, so it might be someone else’s hand and not mine. If this is indeed the case, disownership is the inevitable result of some higher cognitive processing generated by a lack of SA combined with a positive SBO—ownership without agency. This can be experienced as over-presence—a situation in which the disowned limb is experienced as-an-object. In some cases of somatoparaphrenia (Critchley, 1953; Gerstmann, 1942), even when patients are confronted with irrefutable proof that the affected arm is attached to their body, they nevertheless insist the arm belongs to someone else. Yet “whereas known neuroanatomy provides a mechanistic account of GH’s motor and sensory loss, it does not account (directly) for his (pathological) beliefs.” Keeping this in mind, we suggest that at least on some level, somatoparaphrenia is “the patient’s interpretation of what he discovers has (physically) happened to him” and it is “that interpretation that is the proximate cause of (or better perhaps, just is) the somatoparaphrenic delusion” (Halligan et al., 1995, p. 179, my emphasis). Further, knowledge fails to override feelings that this hand is not one’s own, reinforcing the notion that body-disownership can be accompanied by a belief which cannot be dismissed by facts. Indeed, in comparing GH’s experience to the RHI experience, it becomes evident that the experience of body-disownership is much stronger and is accompanied by a strong sense of delusional belief. Moreover, recent fndings (Romano, Gandola, Bottini, & Maravita, 2014) reveal that patients experiencing somatoparaphrenia do not demonstrate physical arousal when their non-belonging [left] arm is under threat. Furthermore, at least in 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 63 this study, patients suffering from anosognosia for somatosensory defcit exhibit “an anticipatory response to noxious stimuli on both hands” (p. 8). GH developed a strong belief that cannot be dismissed by intellectual knowledge or other evidence. This suggests that even if limb-disownership results from a relatively high cognitive process, this cognitive mechanism is activated below the threshold of consciousness and cannot simply be dismissed by referring to high-level cognitive processes.

4.3.1.2 Misoplegia In some cases, somatoparaphrenia is accompanied by misoplegia (Critchley, 1973; Loetscher, Regard, & Brugger, 2006; Pearce, 2007), which is a “morbid dislike or hatred of paralyzed limb(s) in patients with hemiplegia” (Pearce, 2007, p. 62). As Pearce (2007) notes, among other factors misoplegia may result from “disownment of the limb” (p. 62). Critchley (1973) discusses the inability to control a hand and the ensuing helplessness as a key phenomenon that, in turn, may lead to sense of hostility. Misoplegia usually includes “physical acts such as striking and beat- ing the hemiplegic extremity” (Loetscher et al., 2006, p. 1099). For instance, a 79-year-old ambidextrous woman with a tumorous lesion located in the right hippocampus and extending to the medial regions of the right temporal gyrus and the right temporal horn and parietal region, talked to her left leg as though it were another person. She called it rude names, cursed it, and sometimes even beat it, wishing that it “were just dead” (Loetscher et al., 2006, p. 1099). This woman appears to have treated her left leg as an enemy and repeatedly expressed a wish to dispose of the leg—which to her is nothing more than a “bugger”—once and for all. Critchley (1973) describes a patient who denied ownership of her paralyzed arm yet, at the same time, admitted it was hers and tried to remove it violently from her range of sight. Disownership appears to be accompanied by an inherent paradox. For instance, in cases of misoplegia, even if one understands, based on pure logic, that the affected limb is one’s own, one may nevertheless deny this knowledge because one’s feelings completely contradict this knowledge. In turn, the solution to this paradox may be anosognosia (denial or lack of awareness) or disownership. These are two sides of the same coin. If patients do not deny the existence of the problem, they deny that the limb belongs to them. As noted above, in many cases of somatoparaphrenia the patient denies the loss of SA. This insight concurs with Critchley’s 64 Y. ATARIA

(1973) observation that misoplegia results from helplessness and inability to control the hand. One case in point is that of a 10-year-old right-handed boy who experienced an episode of acute loss of consciousness following a spontaneous intracerebral hemorrhage. A brain CT showed a lesion in the deep white matter and basal ganglia of the right temporoparietal region. This rare case demonstrates the following puzzle: On the one hand, the boy denied the existence of a problem, yet on the other hand he revealed unusual attitudes toward his left side:

He was angry about his left limbs, often “hated” them, blamed them, and wanted to get rid of them. In the acute period in hospital he once actually threw himself out of his bed, on to his left side, in an attempt to injure his left arm and leg. He would often bend the fngers of his left hand back- wards, attempting to break them. Both his mother and his physiotherapist reported him as saying that he “would rather destroy it, if he couldn’t use it”. They also reported that he expressed a desire that his left side might be replaced, with that of his mother. (Moss & Turnbull, 1996, p. 210)

Moss and Turnbull (1996) fnd it interesting “that anosognosia and misoplegia coexisted in one patient,” further arguing that “this is surprising given that they refect polar opposites in attitude to the disa bled limbs” (Moss & Turnbull, 1996, p. 210). Yet this coexistence is in no way surprising. In the same way that dissociation and self-harming behavior are two sides of the same coin (Van der Kolk, Perry, & Herman, 1991), anosognosia and misoplegia can coexist. Indeed, this perfectly exemplifes Moss and Turnbull’s observation (1996) that “anosognosia and misoplegia were never present simultaneously. Rather he often switched between hating the left limb and denying his hemipare- sis” (Moss & Turnbull, 1996, p. 210). In cases of disownership, subjects who do not deny the existence of a problem seek to dispose of the affected limb.5

5 It may be that Coltheart’s (2010) two-factor theory suggests at least a partial (theoretical in nature) solution. According to this approach, in order for a delusional belief to emerge, two mechanisms are necessary: “(a) the presence of a neuropsychological impairment that initially prompts the delusional belief and (b) the presence of a second neuropsychological impairment that interferes with processes of belief evaluation that would otherwise cause the delusional belief to be rejected” (p. 16). Hence, we suggest that when the second mechanism ceases to function, the outcome is disownership. 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 65

4.3.1.3 Somatoparaphrenia: A Full-Blown Confict Between Body-Schema and Body-Image Somatoparaphrenia remains the subject of intense debate. Hence, we should refrain from decisive statements concerning its nature. Keeping this in mind, it is possible to suggest that although somatoparaphrenia signifes defcits in body-schema, it does not result only from a lack of SBO. Rather, it is a consequence of denying the loss of SA in the presence of the SBO, which remains partially intact. Apparently, body- disownership can develop over and above the SBO. In fact, disownership can be defned in terms of the over-presence of the affected limb, or side of the body, due to an unbearable paradox: I cannot control my own hand, so it might be someone else’s hand and not mine. To pinpoint this notion, we must understand the discrepancy between the feeling of agency and the judgment of agency (Synofzik et al., 2008). As we saw, whereas the feeling of agency is non-conceptual and implicit, emerging at the body-schema level, the judgment of agency requires that individuals possess strong expectations regarding the result of actions. Hence, judgment of agency functions at the body-image level. Individuals with somatoparaphrenia have lost the feeling of agency; they cannot move the affected limb, yet because their SBO remains at least partially intact, they cannot accept this lack of control: They lose the SA on the level of feeling, yet deny this loss on the level of judgment. The result is an unbearable contradiction between the loss of feeling of agency at the body-schema level and the judgment of agency at the body-image level. To rephrase this notion, these individuals positively judge something (agency) that they should judge negatively. Essentially, this intolerable contradiction between body-schema (feeling of agency) and body-image (judgment of agency) can lead to limb-disownership. Although body-disownership arises due to a mismatch between body- schema and body-image, the contradiction between body-schema and body-image is possible only because of the inner confict at the body- schema level. Feeling of ownership and feelings of agency usually occur together at the body-schema level. Hence, it is only natural to suppose that if a feeling of ownership exists, the feeling of agency should also function. Indeed, as in the case of the anarchic hand syndrome, somatoparaphrenia leaves the feeling of ownership intact while damaging the feeling of agency. This frst-order contradiction within the body-schema facilitates the development of a second-order contradiction between body-schema and body-image. However, this can develop further; the 66 Y. ATARIA second-order contradiction may generate a third-order contradiction: If one judges one’s SA negatively, to remain coherent one may begin also to judge the sense of ownership SBO negatively. Yet, given that one’s feeling of ownership at the body-schema level remains intact, a third- order contradiction develops between judgment of ownership and feeling of ownership. This third-order contradiction enhances the inner confict between body-schema and body-image. Furthermore, if based on the feeling of ownership, one judges the SBO positively, this may lead to an inner confict on at the body-image level between judgment of agency and judgment of ownership. In this way, the basic confict between feeling of agency and judgment of agency can escalate into a full-blown confict between body-schema and body-image. We can now explain why anosognosia (denial of ownership or lack of awareness) and hostility toward the affected limbs may be two sides of the same coin. If one fails to deny ownership, one may develop hostility toward the affected limb. Both reactions occur on the level of judgment of agency (e.g., body-image level) because the individual cannot accept the loss of the feeling of agency at the body-schema level. If the judgment of agency toward the affected limb cannot be controlled, this limb simply cannot be mine.

4.3.2 Body Integrity Identity Disorder (BIID) BIID is a rare6 and unusual psychiatric condition not included in the DSM- 5. Individuals suffering from BIID possess a persistent and ongoing desire to acquire a physical disability—to undergo amputation and thus adjust their actual body to their image of the desired body.7 Beginning in early

6 However, some have suggested that “this phenomenon, although almost certainly rare, may be more common than was originally appreciated” (First & Fisher, 2011, p. 4). 7 A few decades ago scholars identifed and described BIID in terms of Psychopathia Sexualis—sexual attraction to amputees or others with disabilities (Wakefeld, Frank, & Meyers, 1977). However, more recent fndings argue strongly against this thesis (Furth & Smith, 2000). Based on pre/postoperative evaluations, scholars have argued that individuals who undergo this elective amputation (a) do not reveal psychiatric illnesses, and (b) are not sexually attracted to amputees (Fisher & Smith, 2000). Nevertheless, according to a 2005 survey study, the underlying motivation behind these individuals’ desire for amputation is multifaceted and may include both identity and sexual elements. Indeed, two-thirds reported that sexual arousal to the image of themselves as disabled also constituted an important aspect of their desire (First, 2005). Yet the majority (77%) of subjects reported that their primary motivation for desiring amputation was “to feel whole, complete, or set 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 67 childhood, individuals with BIID usually “experience a chronic and dys- phoric sense of inappropriateness regarding their being able-bodied, and many have been driven to actualize their desired disability through surrep- titious surgical or other more dangerous methods.” In fact, they feel that “their anatomical confguration as an able-bodied person is somehow wrong or inappropriate and that they were meant to go through life as a disabled person” (First & Fisher, 2011, p. 3). These individuals seem to sense a fundamental gap between their so-called “true” self as a disabled person and their current able-bodied state. As one of the interviewees in First’s study states: “[After the amputation] I would have the identity that I’ve always seen myself as [having]” (First, 2005, p. 4). Scholars insist that the “phenomenology of BIID cannot be considered delusional given that individuals with BIID do not harbor any false beliefs or cognitions about external reality related to their desire to be disabled” (First & Fisher, 2011, p. 6). The desire to become an amputee is not merely theoretical. Substantial numbers of individuals realize their wish, whether through traditional surgeries such as elective amputation of an otherwise healthy limb or by taking matters into their own hands and freezing a limb in dry ice, for example, making amputation the only remaining alternative.8 We cannot ignore the fact that Smith’s patients reported a signifcantly improved quality of life after amputation, concurring with First’s conclusion (2005): In most cases, the amputation is motivated by a feeling that only becoming an amputee can restore the true self or identity. More specifcally, First fnds that those (six) “subjects who had an amputation at their desired site reported that following the amputation they felt better than they ever had and no longer had a desire for an amputation” (p. 1). Four years after the amputation, Thomas, for instance, states that not only does he feel no regret whatsoever about the surgery but, he stresses, “my only regret is that I did not have it done sooner” (p. 2). right again” (i.e., correcting an identifed mismatch). The question of the sexual com- ponent of BIID is fundamental and cannot be ignored. That being said, in the last few years, scholars have reached at least partial agreement that “sexual arousal is rarely the primary explanation of the desire to change one’s own anatomy” (Brugger, Lenggenhager, & Giummarra, 2013, p. 3), yet nevertheless “it is worthy of attention with respect to the ontogeny and phenomenology of the condition” (p. 3). 8 We should also note that approximately two-thirds of individuals with BIID who have undergone amputation of a major limb (i.e., arms or legs) used methods that risked serious injury or death (i.e., shotgun, chainsaw, wood chipper, and dry ice) to dispose of the unwanted limb. The remaining third in this study managed to convince a surgeon to perform the surgery (First, 2005). 68 Y. ATARIA

Quite similarly to somatoparaphrenia, BIID also involves a strong belief that a limb is not one’s own, or more precisely that one is situated in the wrong body. As we saw, these beliefs apparently cannot be treated as delusional (First & Fisher, 2011). In the case study of Thomas—a 39-year-old man who underwent elective amputation of the left leg above the knee—living with the unwanted limb not only depressed him but led him to contemplate suicide. Yet unlike somatoparaphrenia, BIID occurs even though the relevant affected limbs “are experienced as being under full control of the individual” (Giummarra, Bradshaw, Nicholls, Hilti, & Brugger, 2011, p. 321). Therefore, if we defne BIID in terms of disownership, then disownership can almost inevitably be generated even when the SA remains intact. Thus, disownership results neither from a lack of sense of ownership nor from a lack of SA but rather from a basic clash between the feeling of ownership and the feeling of agency at the body-schema level. Yet, as we will see, although this confict is necessary it is insuffcient alone to generate disownership. As part of a general trend, during the past few years researchers have argued that “BIID may be a parietal lobe syndrome, rather than being purely psychological in its origin” (Sedda, 2011, p. 335). A number of factors that support this notion: (a) The desire for amputation is almost three times more common for the left leg than for the right leg; (b) there is a similarity between BIID and somatoparaphrenia; and fnally (c) the patient can trace out the precise line where the amputation is desired—a line that typically remains stable over time. Yet at the same time, it seems impossible to understand this phenomenon based purely on brain activity. Indeed, Hilti et al. (2013) argue that xenomelia—foreign limb syndrome—“is not a disorder that can readily be ‘localized’ to any circumscribed region of the human brain” (p. 323). In particular, the switch of a long-standing desire from a left-sided to a right-sided leg amputation or an abrupt desire for a new amputation after previous such wishes were met is not so easily explained merely by referring to neural mechanisms.

4.3.2.1 BIID and Body Maps in the Brain: Incarnation Without Animation First and Fisher (2011) compare BIID with phantom limbs. According to them, an individual with BIID “is akin to the patient 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 69 with phantom limb sensations who has the feeling that his missing limb is still a part of his body while acknowledging the reality that it is in fact absent” (First & Fisher, 2011, p. 6). In effect, BIID is a mirror image of the phantom limb phenomenon, because those suffering from BIID want to become amputees. They feel the affected limb is not part of their body yet acknowledge the reality that it is in fact a part of them. While phantom sensations can be described as “animation without incarnation,” we can defne the desire of non-psychotic individuals to amputate a healthy limb as “incarnation without animation” (Hilti & Brugger, 2010, p. 315). In both cases, the individual experiences a fundamental disparity between incarnation (the actual physical body) and animation (body map). Accordingly, in the case of phantom sensations of congeni- tally absent limbs, sometimes even accompanied by phantom pains, the subject develops as if experiences concerning a limb that physically does not exist. In contrast, in the case of BIID, “the affected limb may be entirely functional, yet lack the sort of animation we usually feel to be an intrinsic property of any part of our own body” (Hilti & Brugger, 2010, p. 322). If the notion of incarnation without animation is somewhat correct, then to understand the nature of BIID we must focus on how body is represented in the brain’s neuronal maps. A good starting point, at least as an initial hypothesis, is to suggest that the problem may lie in the offine map of the body, at the level of the long-term-body-model (LTBM). This may explain why in many cases individuals with BIID develop a desire for amputation at quite a young age. Indeed, studies reveal that around 92% of those reporting a desire for amputation already exhibited during childhood pretend behavior that included binding the leg back or using a wheelchair or other such devices (e.g., crutches or fake hooks), regardless of their sexual development (maturation) (First, 2005). In order that a strong (yet not too strong) SBO exists, the limb must become experientially transparent; for this to happen, it must be fxed within the LTBM. As we previously saw, the sense of transparency is produced by the LTBM. In other words, unless the prosthesis is naturally geared into the LTBM it will never become transparent and consequently cannot become part of the body-as-subject. Therefore, 70 Y. ATARIA we suggest that the LTBM enables prostheses to become part of the lived-body. If, however, the LTBM does not include the left hand, for example, then the individual will not be able to feel that the left hand is part of the lived-body: The left hand might be part of the body-as-object but not part of the body-as-subject. In this case, although one may know that the left hand is one’s own, one will nevertheless be unable to feel it. In this situation, the sense of limb-ownership is clearly lacking. Returning to the phenomenology of those seeking amputation, this thesis is enhanced: “I would feel whole without my leg” (First, 2005, p. 4), states a person who wishes to become an amputee. It thus seems possible to argue that the unwanted limb is simply not part of the LTBM; hence in order to feel complete, the individual must adjust the physical body to correspond with the LTBM. BIID is apparently an outcome of some basic confict between the different levels on which we experience our body. In turn, this contradiction might lead to a sense of disownership toward a limb, as in the case of compulsive targeted self-injurious behavior: Subjects who experience neuropathic pain identify the specifc area in the body responsible for their pain and cause harm to it (Mailis, 1996). Studies demonstrate that, as in the case of BIID, those suffering from neuropathic pain behave toward “their affected limb as if it were not part of their body” and even express a “desire to amputate this part” (Lewis, Kersten, McCabe, McPherson, & Blake, 2007, p. 111). Thus, it has been suggested that, as in the case of BIID, “the disorder postulates a lack of mental representation of the body part against which physical self-aggression is directed” (Hilti & Brugger, 2010, p. 323). Hence, the absence of a body limb in the long-term body map can seemingly lead to an uncontrolled desire to dispose of the affected limb. Yet the frst-order contradiction at the level of body-schema between feeling of ownership and feeling of agency is not suffcient to generate such a feeling. A second-order contradiction is likewise necessary.

4.3.2.2 Body-Ownership Versus Body-Disownership First fnds (2005) that when subjects suffering from BIID were asked whether the limb felt “like it was not their own,” only thirteen per- cent responded positively. Hence, while at least 87% did not lose their body-ownership, they nonetheless developed disownership toward the affected limb. 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 71

Keeping this in mind, we now can ask: How can an individual simultaneously own and disown the same limb? Let us rephrase the problem: Based on the working hypothesis that BIID emerges when the affected limb is not represented within the LTBM (not part of the lived-body), impairments at the body-schema level are the inevitable outcome. This being the case, the obvious question is: How can the SBO remain intact? To answer this question, we must return to the notion of a double dissociation between body-schema and body-image, together with the difference between feeling of ownership and judgment of ownership. Feeling of body-ownership is non-conceptual and rooted within the most basic sensorimotor loop, thus clearly occurring at the body-schema level. In contrast, judgment of body-ownership is explicit and occurs at the body-image level. Impairments in the sensorimotor loop may lead to defects at the body-schema level, which, in turn, can result in defciencies in the SBO. Under such circumstances, individuals seek the best explanation for the current situation by means of high-level interpretative cognitive processes. These processes ultimately lead individuals either to believe that, despite the mismatch, they own their body or else to conclude that they do not own the body. Such a solution emerges on the level of judgment of body-ownership, namely, at the body-image level. Let me explain this notion further. Despite the lack of SBO, some nevertheless insist that the body is their own. These individuals appear to describe what they know to be logical rather than what they feel, so that their so-called feeling of ownership is in effect a judgment of body-ownership. In contrast, those who conclude that they do not own the body can solve the problem by developing a delusional belief that the affected body part belongs to someone else, as in the case of somatoparaphrenia. Alternatively, they can leave the problem unresolved by developing a delusional belief that a body part does not belong to them (e.g., asomatognosia). Solutions of this kind are only available because somatoparaphrenia is characterized by a lack of feeling of agency, which is not the case in BIID. Those suffering from BIID have lost the feeling of ownership. Yet based on their system of beliefs and habits as well as the evident reality that the limb is attached to the body, and given that their SA has remained intact (unlike in the case of somatoparaphrenia), their judgment of body- ownership rejects (top-down) their lack of feeling of body-ownership. This leads to a fundamental contradiction between the (lack of) 72 Y. ATARIA feeling of body-ownership (bottom-up) and the judgment of body- ownership (top-down). This second-order contradiction is marked by a confict between the SBO at the body-schema level (feeling) and the judgment of body-ownership at the body-image level. Thus, we propose that body-disownership, at least in the case of BIID, results from a mismatch between body-image and body-schema. Let us now return to the question of how 87% of those with BIID can report they have not lost their body-ownership. We suggest that their reply relied on their judgment of ownership, which is more accessible to (naïve kind of) introspection, rather than on their feeling of ownership. The same solution applies to the following question: If BIID is accompanied by impairments at the body-schema level, how can the SBO remain intact? In replying to this question, we may say that it is not the feeling of ownership or the SBO but rather the judgment of ownership which remains at least partially intact. Let us clarify this point: Comments such as “these are my legs” clearly indicate a problem because when everything is functioning properly we do not pay attention to our body.9 It is quite strange to hear someone saying: “this is my body.” Of course it is your body; who else could this body belong to? Indeed, such a statement conceals more than it reveals; sometimes “what is essential is invisible to the eye” (de Saint-Exupéry, 1971). When subjects make statements such as “these are my legs,” they are in fact saying they know these are their own legs. Yet at the same time, they are also saying that, at least to some extent and in some cases, they do not feel these legs are their own. As is evident from the case of prostheses, knowing is one thing and feeling is something else entirely. Subjects know their legs are their own because they are attached to their body. Yet they do not feel that these legs belong to them. In principle, this is not a contradiction, because based on several factors, the subjects seemingly know these legs are their own. Nevertheless, they do not develop an internal feeling of ownership toward these legs. In other words, subjects appear to embrace a 3PP toward their legs, while at the same time they lack the 1PP knowledge (e.g., the actual feeling) that these legs are their own.

9 Anyone who is closely familiar with cardiac patients knows how aware these patients are of what normal people are incapable of discerning the amount of air that enters their lungs. For most of us, this information is beneath the threshold of consciousness. These patients also notice every minor incline on the sidewalk, because even the smallest change in their oxygen consumption has a dramatic impact on them. 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 73

Hence, we may argue that body-disownership is the result of a colli- sion between feeling and judgment: The lack of feeling of ownership at the 1PP or body-schema level contradicts the judgment of ownership at the 3PP or body-image level. This inherent 1PP/3PP body-schema/body-image confict can potentially result in body-disownership, expressed in a sense of over-presence, for neither feelings nor knowledge can be ignored. This sense of over-presence is fully compatible with the phenomenology of BIID, as noted by one of the participants in a study conducted by Blanke, Morgenthaler, Brugger, and Overney (2009): “My leg is somehow too much” (p. 187, my emphasis). Thus, the combination of (a) a lack of feeling of ownership, (b) an intact feeling of agency, and (c) an intact judgment of body-ownership can lead to a sense of the body’s over-presence, which is in fact an expression of limb-disownership. Cutting off the offending limb is an attempt to synchronize between feeling and knowledge.

4.3.2.3 BIID: Basic Insights As in the case of somatoparaphrenia, BIID is a relatively complex phenomenon, and we are still far from fully comprehending it from either the phenomenological or the cognitive perspective. Nevertheless, we propose the following insights. BIID entails a strong belief that one is located in the wrong body and that the limb does not belong to oneself. Yet, similarly to the alien hand syndrome, one possesses the ability to control this body—which does not feel as though it is one’s own. We may argue that BIID is frst and foremost an outcome of an inherent confict within the body-schema: Whereas the feeling of ownership is lacking, the feeling of agency remains intact. This frst-order confict may in turn lead to a second- order clash between body-schema and body-image. This twofold confict is responsible for the devastating outcomes of this phenomenon. We saw that BIID involves impairments at the level of the long-term body map (“incarnation without animation”) and at the level of body- schema. Thus, those with BIID seemingly embrace a 3PP perspective toward their body and similarly to Ian Waterman experience their own body at the level of body-image—as-an-object. This also explains why individuals with BIID may report a normal SBO. In fact, they are describing their judgment of ownership occurring at the level of body- image. Interviews with such individuals (Blanke et al., 2009; First, 2005) 74 Y. ATARIA almost always deal with the body-as-object (judgment) and not the body- as-subject (feeling). Hence, these answers are quite predictable.10 Continuing this line of thought, and as noted earlier, individuals with BIID may know that this body is their own—at the body-image level and from a 3PP (body-as-object)—yet, nevertheless, they do not feel that they own the body due to problems at the body-schema level (body-as-subject). As a result, an intolerable confict may emerge between body-schema and body-image, leading, in some cases at least, to body-disownership. At this point, we propose that although body-disownership and SBO are closely related, body-disownership is not the same as a lack of SBO and cannot be located on the body-ownership spectrum.

4.3.3 Some Insights Concerning Limb-Disownership Scientifc literature (de Vignemont, 2010) defnes somatoparaphrenia and BIID as types of disownership. Based on this defnition, we propose some new insights concerning limb-disownership: Body- disownership does not result from a lack of SA or a lack of sense of ownership. Rather, it is caused by a twofold mismatch: Whereas the frst-order contradiction between feeling of ownership and feeling of agency at the body-schema level, the second-order contradiction between feeling of agency (body-schema) and judgment of agency (body-image), or between feeling of ownership (body-schema) and judgment of ownership (body-image). As this mismatch between body- schema and body-image becomes increasingly intolerable, the outcomes become more severe. This chapter has demonstrated that due to a contradiction between the SBO and the SA at the body-schema level, a mismatch emerges between body-schema and body-image. This twofold incongruence can result in limb-disownership. This same reasoning can be applied to the

10 Interestingly, when patients suffering from somatoparaphrenia saw their affected hand directly in the mirror (as a refection), they once again felt a sense of ownership toward their hand. However, “the habitual disownership returned seconds after the mirror was removed and was repeatedly remitted every time the mirror feedback was provided.” Thus essentially, “the two opposite judgements (i.e., this arm is mine vs. this arm belongs to someone else) alternated within seconds and this did not seem to be noteworthy to either patient” (Fotopoulou, et al., 2011, p. 3591). Based on these fndings it seems at least possible to suggest that there is a fundamental gap between 1pp and 3pp, that is it to say that experiencing one’s body from a frst person perspective, on the one hand, and experiencing one’s body from a third person perspective, on the other, are rooted in different kinds of mechanism. 4 WHEN OWNERSHIP AND AGENCY COLLIDE … 75 entire body. The next chapter discusses the contradiction between SBO and SA at the level of the whole body. As in the case of a limb, the outcome can be body-disownership.

OwnershipAgency Body-Schema Feeling of Feeling of ownership agency

Second order contradiction First order contradiction

Body-Image Judgment of Judgment of ownership agency

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The Complex Relations Between SA and SBO During Trauma and the Development of Body-Disownership

5.1 dissociation—A Defense Mechanism Activated During Trauma Dissociation is defned as the “lack of normal integration of thoughts, feelings, and experiences into the stream of consciousness and memory” (Bernstein & Putnam, 1986, p. 727). Janet (1889, 1925) regarded dissociation as an unconscious defense mechanism activated during trauma to reduce the impact of the traumatic experience. Yet to date researchers have not reached any consensus regarding whether peritraumatic disso ciation “serves defensive purposes or constitutes integrative failure” (Van der Hart, Nijenhuis, Steele, & Brown, 2004, p. 907). Hence, McNally rightly asks how we can distinguish “acute reactions to trauma arising from properly functioning mechanisms from those arising from dysfunction in these mechanisms” (2003b, p. 779). From a phenomenological perspective, a dissociative experience can be defned in terms of a split between the body-as-subject and the body-as-object, with the equilibrium shifting toward the body-as- object. Under these circumstances, the body can no longer serve as a reference point for the world, or using Merleau-Ponty’s words: “I am no longer concerned with my body, nor with time, nor with the world, as

This chapter is based on a combination of several papers (Ataria, 2015a, 2015b, 2015c; Ataria & Neria, 2013).

I experience them in antepredicative knowledge, in the inner commun- ion that I have with them” (Merleau-Ponty, 2002, p. 82). As a result, the individual begins to develop a sense of alienation, accompanied by a sense of not being-at-home within-the-world. Indeed, Leder (1990) suggests that under such circumstances we no longer act from within the body but instead direct our actions toward it. In extreme cases, the body “becomes a mere tool and a mere object” (Dorfman, 2014, p. 77)—an IT (Scarry, 1987). As noted, dissociation may serve as a defense mechanism during trauma. Van der Kolk (1987) believes that this mechanism, also known as peritraumatic dissociation, can be adaptive in the short term, yet in the long term it may become pathological, leading to a variety of symptoms. Many scholars claim that peritraumatic dissociation may interfere with the encoding process during trauma, increasing the likelihood that the individual will eventually develop post-traumatic stress disorder (PTSD) (McNally, 2003a; Spiegel, 1997; Van der Kolk & Van der Hart, 1989). Scholars tend to link dissociation during trauma with PTSD, claim- ing that individuals who exhibit peritraumatic dissociation are at greater risk of developing chronic PTSD: “the greater the dissociation during traumatic stress exposure, the greater the likelihood of meeting criteria for current PTSD” (Marmar et al., 1994, p. 902). Indeed, compared to other risk factors, “peritraumatic dissociation during or immediately following a traumatic event is considered to be an important risk factor for the development of mental health disturbances such as PTSD” (Van der Velden & Wittmann, 2008, p. 1010). According to a meta-analysis conducted by Ozer, Best, Lipsey, and Weiss (2008), in comparison with six other risk factors—prior trauma, previous psychological adjustment, family history of psychopathology, perception of a life-threatening situation during the trauma, post-trauma social support, and peritraumatic emotional responses—peritraumatic dissociation is the strongest predictor of PTSD symptomatology. This is especially true for the “development of chronic PTSD” (Marmar, Weiss, & Metzler, 1998, p. 233).

5.2 weakening of the SBO During Trauma As discussed in Chapter 2, Merleau-Ponty (2002) asserts that “A Theory of the Body is Already a Theory of Perception” (p. 235). If, indeed, we perceive the world through our bodies, we may say that when the sense of body-ownership (SBO) decreases, the world around us will become 5 THE COMPLEX RELATIONS BETWEEN SA AND SBO DURING TRAUMA … 83 strange to us, unlike the “already familiar world” (Merleau-Ponty, 2002, p. 327) in which we usually exist. In more extreme cases, those marked by a total lack of sense of ownership, the individual may feel that the world has ceased to exist. To understand this, we must bear in mind that the essence of subjectivity is “bound up with that of the body and that of the world,” and thus, “the subject that I am, when taken concretely, is inseparable from this body and this world” (Merleau-Ponty, 2002, p. 475). SBO is situated at the very core of the subjectivity–body–world tri- angle and thus grounds the individual in-the-world at the body-schema level. Any change in SBO level affects how the individual is thrown into the world. For instance, when the SBO lessens, the individual feels at least partially detached both from the body and from the world. In that sense, changes at the level of SBO can serve as a shield: A drop in SBO enables the subject to disconnect from the incident, yet continue to function, at least to some extent. According to Van der Kolk and Saporta (1991), the biological defense mechanism activated during trauma blocks the individual’s awareness of what is happening. Activation of this biological defense mechanism in turn weakens the SBO, causing individuals to perceive the world in a distorted manner. If the traumatic event continues, the individual can become dissociated from his own body and from the world, as exemplifed by the testimony of I., a former prisoner of war (POW):

The world starts to be , distorted, like objects in space that lose their meaning… I become more and more distant from what is happening to me now… it’s like the unreal starts and as it gets stronger torture I just get further away from the body, from the world and from life… But I am still there, even understanding part of what is happening around me, I am not totally cut off and not completely there, the body is mine and is not really mine… I understand more or less what is going on but don’t really understand that it is happening to me. (Ataria, 2010, p. [unpublished testimonies])

I. feels his body slipping away from him. In cognitive terms, we may say that his SBO is weakened. Yet he is not yet totally dissociated, because the equilibrium between body-as-subject and body-as-object has not totally collapsed. Likewise, I.’s surroundings have become distorted, twisted, and unreal. In more extreme cases, the SBO becomes even weaker and the subject becomes dissociated from the body as well 84 Y. ATARIA the world. This is true in the case of Robin, a 32-year-old survivor of incestual sexual abuse: “What I decided to do was to separate my body and my mind” (Herman, 1992b, p. 225). Her response to this life-threatening situation is equally extreme: total separation from her surroundings. Some responses are yet more severe, for example, the out-of-body- experience described by a rape survivor:

I left my body at that point. I was over next to the bed, watching this happen…I dissociated from the helplessness. I was standing next to me and there was just this shell on the bed…There was just a feeling of fatness. I was just there. When I repicture the room, I don’t picture it from the bed. I picture it from the side of the bed. That’s where I was watching from. (p. 43)

Thus, at least in the short term, a weakened SBO during trauma can apparently serve as a fexible defense mechanism, enabling subjects to separate themselves from an unbearable reality. Let us consider this notion further by examining various testimonies provided by survivors of terror attacks.1 Z.O., for example, describes her experience in the following words: “And I’m looking, like this isn’t my body, you know, I’m cut off from reality. I’m looking, not talking, not moving, not anything. Cut off ” (Z.O.). Indeed, Z.O.’s testimony implies that the dissociative experience can be explained at least partly in terms of weakened SBO or its absence. The disconnection from both the body and the world results in a feeling that the individual is not really the one undergoing this experience. As noted, SBO is not a yes/no mechanism but rather operates on a continuum. Evidence from interviews appears to support the notion that sense of ownership can be reduced to various degrees. For example, R.M. feels some degree of familiarity with her body: however, it is not exactly her own body, but rather a body for functional purposes only:

1 Unless otherwise noted, all the testimonies in this and the next two sections are quoted from my previous study (Ataria, 2015a), for which thirty-six victims of terror attacks (including suicide bombings on buses and in other crowded areas, stabbings, and rocket attacks from Gaza and Lebanon) were interviewed. The interviewees were aged 22–78 (mean age 50.56, SD = 12.26), 13 men (7 severely injured) and 23 women (3 severely injured), all recognized by the Israeli National Insurance Institute as suffering from PTSD (with more than 20% disability), all members of the charitable organization One Family (a non-proft organization), and all scoring more than 44 (44 < 85) on the PCL questionnaire, a 17-item self-report scale for PTSD based on the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV. It should be noted that the collection of data for this research was part of a more extensive quantitative research study conducted by Dr. Michael Weinberg, Prof. Avi Besser and Prof. Yuval Neria and supported by Psychology Beyond Borders (PBB). For more methodological issues see Appendix 1. 5 THE COMPLEX RELATIONS BETWEEN SA AND SBO DURING TRAUMA … 85

“I recognize it, the body, but not like I know it to be normally. It’s a functional body that represents some kind of new reality, but it is not really ‘my body’” (R.M.). Z.H. expresses the same concept in slightly different terms: “I was there and I wasn’t there” (Z.H.). Both R.M. and Z.H. underwent similar experiences, during which their SBO declined, in turn, they experienced partial detachment from the body, expressed in a being/ not-being kind of experience that can be defned as a semi-dissociative state. Although at frst R.M. apparently retained at least a weak SBO, over the course of the traumatic incident this weakened further; eventually, she felt that her body was merely an object to which she was not attached: “It’s a kind of object… fesh… without ownership. There’s no ownership. Just another object…. I wasn’t connected to the body at all” (R.M.). Yet apparently the SBO can become even weaker. R.M. describes an OBE: “It’s not R.M. in the body now, R.M. is in another place, not inside the body” (R.M.). M.J., A.E., and Z.H. report very similar experiences:

“I felt like I died – I’m not there at all, it’s not mine, I’m in another place” (M.J.); “It’s possible that I was in another place, because I wasn’t there” (A.E.); “I see everything from outside…everything that happened. I felt like I was looking at everything from above, and I’m not there, I’m just looking”. (Z.H.)

5.3 loss of SA According to Spiegel, “traumatic stress is the ultimate experience of helplessness2 and loss of control over one’s body” (1997, p. 227). Hence, the SA clearly plays a fundamental role during trauma. As we have seen, SA can be either strong or weak—it is not a yes–no mechanism.

2 According to the Merriam-Webster dictionary, helplessness is a situation in which you are “not able to defend yourself.” Similarly, the Cambridge English Dictionary char- acterizes helplessness in terms of being “unable to do anything to help your[one]self or anyone else.” Other dictionaries defne helplessness as a feeling of being “powerless or incompetent” or “deprived of strength or power; powerless; incapacitated.” In addition, helplessness defnes a situation that the individual fnds “impossible to control.” None of these defnitions designates physical injury as a precondition for developing a sense of helplessness. 86 Y. ATARIA

In a traumatic situation, K.B. completely lost her ability to function, to the extent that she was unable to protect her own children: “When I heard the boom I couldn’t go out and I couldn’t move, I had a kind of black out and I froze on the spot. My children were outside and I couldn’t go out and get them” (K.B.). K.B. was unable to function under extreme stress—“I kind of froze and then I fainted” (K.B.)—indicating that her SA had collapsed: “It’s happened to me many times during this period, when I was in the car, the siren would go off, and I couldn’t get out of the car or take cover or run anywhere. I was just frozen” (K.B.). O.S. is another mother who, in her own words, lost her ability to function during a traumatic event. Indeed, seven years later, she remains unable to accept her perceived failure: “I was stuck… I was frozen. My daughter was outside the door and I couldn’t get it open for her. My hand wouldn’t move. I’m frozen. That doesn’t leave me. All day long that thought is with me” (O.S.). Such responses to stressful situations are not uncommon. Indeed, B.A. describes a comparable experience, during which she was unable to move her body to take cover and felt frozen to the spot:

My legs didn’t move. People shouted, I hear the shouts, get out of the way quickly! Run, run! I hear the people’s shouts. Only my eyes and my ears work. My body won’t move. My legs won’t move. Completely paralyzed, I am not doing anything to help myself. (B.A.)

Similarly, H.C. describes her experience in the following manner:

I hear the noise of the rocket, the wooosh…passing over us. I couldn’t do anything. All of a sudden my legs froze and it’s like they were made of concrete. My legs won’t work…I can’t run. Even if I want to run, I can’t. People around me are running and taking cover but I can’t do anything. It’s not in my control. My child is with me and I can’t help myself to help him. (H.C.)

We must distinguish between those situations in which individuals can help themselves (fght or fight) and those in which no such option exists, as is exemplifed by the case of A.R. Whereas H.C. and B.A. could improve their situation by running for cover, under heavy bombing A.R.’s only alternative was to remain motionless. He had already done everything in his power to help himself: “You’re like a fossil or paralyzed under a rock…you have nowhere to run to” (A.R.). Note, however, that freezing ensues whether or not it is possible to improve the situation: “It’s like being frozen” (R.M.). 5 THE COMPLEX RELATIONS BETWEEN SA AND SBO DURING TRAUMA … 87

Interestingly, most post-traumatic individuals who managed to function during trauma insist they simply cannot explain how they did so: “I don’t know how I functioned, but I functioned excellently during the event itself. I can’t explain it. I also can’t explain to you what exactly I did” (S.E.). Many feel they were acting on automatic pilot, as if they were simply robots, indicating emotional numbness: “I functioned like a robot” (Z.B.); “I functioned like a robot, like a machine” (S.E.); “I was on automatic pilot” (S.A.). Thus, to clarify this matter, we must improve our understanding of the reciprocal relationship between SBO and SA.

5.4 the Relations Between SBO and SA During Trauma As noted, many of the interviewees report feeling a loss of control over their own bodies during the traumatic event; their bodies no longer obey their commands and become frozen or paralyzed. Yet E.G.’s testimony suggests that even under such circumstances the individual nevertheless possesses an SBO:

I remember myself shouting out “help, help.” But I can’t move. In front of me, 5–10 meters away, there’s a shelter and I can’t run. People in the shelter are shouting to me “Come!” and I’m saying to them “I can’t!” I feel like my feet are rooted to the spot. My legs aren’t listening to me. I see the rocket coming towards me. Like that. And I’m…shouting to them…”Rocket!” I’m trying to pick up my legs with my hands but it’s like they’re made of concrete. I want to move and I just can’t. I have no control over my body…. I’m not detached, I’m totally present, it’s a nightmare. (E.G.)

Although E.G.’s body did not respond to her commands, she did not lose her SBO (I’m trying to pick up my legs with my hands…I’m not detached, I’m totally present). Rather, she has lost the SA over her body. We previously noted that SA and SBO are rooted in different kinds of mechanisms. Hence, a weakened SA does not necessarily indicate that one’s SBO has also been damaged. To retain control during traumatic situations, the victim must seemingly become emotionally detached, at least to some extent. In this sense, the weakening of the SBO appears to act as a defense mechanism, allowing the victim to retain control over the body. Phenomenologically speaking, in this situation one feels that one controls a body which is not exactly one’s own, Z.H, for example, 88 Y. ATARIA describes her experience as follows: “I was functioning, I checked the children, I calmed them down. I was so stressed but I functioned like I wasn’t connected to there…like everything was fne and calm. You’re detached and you function. Like automatically” (Z.H.). Evidently, Z.H. (as well as Z.B., S.E., S.A.) experienced dissociation yet continued to function automatically. One possible explanation is that individuals who are able to function do not lose their SA completely—a weak SA continues to function. Thus, while E.G.’s reaction (I want to move but I just can’t. I have no control over my body) during the traumatic event represents a total loss of SA, Z.B. was able to function, suggesting that SA declined but did not disappear altogether. Interestingly, while Z.B. experienced a fundamental decrease in SBO, E.G. did not demonstrate any signs of diminished SBO but rather apparently lacked any SA whatsoever. In fact, she states: “I have no control over my body” (E.G). It thus seems that SBO can be activated without SA. Indeed, E.G., who was unable to function, testifes that she lost control over her body but retained her SBO. If the SBO remains intact but SA declines, this leads to a disparity between SA and SBO, such that SBO > SA. Keeping this in mind, let us now return briefy to the cognitive mechanism responsible for the development of somatoparaphrenia as an extreme case of anarchic hand syndrome. We can now defne this mechanism as SBO > SA, resulting in limb-disownership. As the ratio SA:SBO approaches zero, the likelihood grows that a stronger disownership reaction will develop. Thus, whereas at one extreme the SA declines and the SBO remains untouched, at the other extreme the SBO drops while the SA remains intact.3 Yet both cases represent a disparity between SBO and SA. Let us examine this point further among prisoners of war (POWs).4 Whereas terror attacks are considered trauma-type-I a traumatic event

3 Note that this can result from a change in the numerator, the denominator, or both. 4 Unless otherwise noted, all the testimonies from this point onward in this section are quoted from my previous study with prisoners of war (Ataria & Neria, 2013) for the purpose of which, ffteen Israeli ex-prisoners taken captive during the 1973 Yom Kippur War were interviewed. Each interview lasted between one and four hours, and all were recorded and subsequently transcribed. The interviewees were male combatants in the war, whose military roles varied from combat pilots to infantry soldiers. They were held in captivity in Syria, Egypt, and Lebanon and experienced periods of isolation ranging from 36 days to three- and-a-half years. At the time of the interview, the subjects were between 59 and 71 years old. Apart from one subject, the native language of all the interviewees was Hebrew. 5 THE COMPLEX RELATIONS BETWEEN SA AND SBO DURING TRAUMA … 89 which occurs at a clear point in time and not over a prolonged period, POWs undergo severe and ongoing trauma. Therefore, examining testimonies given by former POWs, we can shed light on the relations between SA and SBO during cases of trauma type-II. Endeavoring to survive total isolation during captivity, prisoners necessarily “isolate” themselves from their own body: “I put myself into a bubble” (L.) so that “it is the body which suffers and not the soul” (L.). Many captives describe such detachment experiences: “From the moment that I was caught there was no body. I was completely cut off from the body,” and D. continues: “In captivity the body was as if it were not completely mine. It was a tool which they could use to hurt me, or a tool which produced pain and discomfort” (D.). These testimonies indicate that the SBO is diminished while the individual is in isolation. As a captive, the individual has little, if any, control: “One of the things is that you don’t have control over your life. You are almost like an object” (S.). The analogy to an inanimate object is not coincidental. An inanimate object is passive, a “thing” that is simply moved from place to place. If we accept that a sense of control is vital for human existence, it is clear why a captive obsessively tries to achieve this. In order to confront the continuing uncertainty and painful loss of control over the “real” world, the captive seeks to create a framework, some dimension in which a degree of certainty exists. This is often achieved via control of the inner world, the world of thoughts: “You are in zero control, so what I did is to cut myself off from this impossible reality was to start to delve into my thoughts” (L.). Thinking is an effective way to detach from pain and uncertainty: “When there is darkness you don’t know what is in front of you and then you can’t be in control. In a situation like this the instinct is to close your eyes because you will feel better” (H.). These interviews reveal that by reducing their SBO, the POWs were able to regain some degree of control over their inner world. Indeed, D. testifes that while his body “belonged to captivity” his mind remained his own: “My head was mine, you couldn’t lose that. The battle was in your head” (D.). Clearly, the SBO is diminished, yet the SA becomes stronger. Whereas this mechanism enables prisoners to survive in the short term, it generates a disparity between SA and SBO, as in the case of BIID. In such cases, relations between the SA and SBO tend toward the SA (SBO < SA). Similarly to the case of BIID, disownership is a possible outcome. The remainder of this chapter will examine in detail the conditions that may lead to the development of body-disownership. 90 Y. ATARIA

5.5 the Development of Body-Disownership In our daily lives, the SBO and SA go hand in hand. In essence, the relations between these independent yet closely connected mechanisms determine whether or not a victim will be able to function during trauma. To be more specifc, the relations between ownership and agency are responsible for the nature of the dissociative response rather than the absolute value of either of these mechanisms.5 Keeping this in mind, we can now confront, at least to some degree, McNally’s important question: How can we differentiate “acute reactions to trauma arising from properly functioning mechanisms from those arising from dysfunction in these mechanisms?” (2003b, p. 779). Based upon the above analysis, we contend that the most signifcant factor in answering this question is the ratio between SA and SBO: As long as SA:SO 1, the dissociative mechanism allows us to function. Yet as the = SA:SO ratio approaches either zero or infnity, the dissociative mechanism becomes dysfunctional. To clarify this notion, let us return to the example of prostheses and tools: SBO and SA are both weaker in reference to tools than to prostheses and are likewise weaker for prostheses than for one’s biological body. If a strong sense of ownership could somehow to be projected onto an uncontrolled tool, a strange feeling would emerge—exactly as in the case of the anarchic hand syndrome. Similarly, if for some reason the SA toward a biological limb were weakened, the

5 Clearly, it is possible for both sense of agency and sense of body-ownership to decline rapidly, yet under such circumstances one cannot function. Scientifc literature (Baldwin, 2013; Bracha, 2004; Kozlowska, Walker, McLean, & Carrive, 2015) defnes this phenomenon as collapse or faccid immobility. Under severe stress, and when the threat is perceived as impossible to handle, this tonic immobility (characterized by stillness, fxed eyes and stomach tension with a pounding heart rate of 100 bpm, and fast shallow breathing) turns into faccid immobility or fainting, including an extraordinary drop in heart rate and blood pressure. This state is characterized by faccid immobility (foppiness) and glazed or averted eyes, accompanied by bradycardia (HR 60 bpm) and slow, shallow breathing. ≤ Numbness and analgesia (endogenous opioids) may also occur. According to Schauer and Elbert (2010), this stage can be defned as a system shut-down. Flaccid immobility cannot be switched on/off easily. It is not a yes/no reaction and has a slow onset and a slow termination. On the one hand, muscle stiffening changes to faccidity and voluntary movements stop, as does speech, over the course of only several minutes. On the other hand, it may require several minutes or even hours for one to become oriented back into reality from this state. Clearly, in this situation, both SBO and SA drop to zero: one cannot control a body that is not one’s own. 5 THE COMPLEX RELATIONS BETWEEN SA AND SBO DURING TRAUMA … 91 individual would probably also feel uncomfortable. In both these cases, SA:SBO < 1.6 However, if one could have perfect control over a prosthesis yet at the same time feel that the prosthesis was not one’s own, one would feel uneasy and awkward: SA:SBO > 1, just as in the case of the alien hand syndrome. Based on this model, and given that during trauma the individual loses control (in cognitive terms the SA is weakened), we may argue that for the individual to continue functioning during trauma, the SBO must decline as well. If not, the SBO will become too strong: SA:SO < 1. Indeed, while the SA and SBO remain somewhat equivalent (SA:SBO 1), the individual can function. Yet if the SBO is not ≈ suffciently weakened or becomes too weak (compared to the SA), a discrepancy emerges between SA and SBO at the body-schema level. As we saw in the cases of somatoparaphrenia and BIID, limb- disownership is a possible outcome of this SA-SBO contradiction. Those cases indicated that beyond the necessary condition of a frst-order clash at the body-schema level, a second-order contradiction between body- schema and body-image is also required. This same dual mechanism can be activated in the case of the whole body and, subsequently, body- disownership may develop. The case of Jean Améry offers an opportunity to examine the phenomenology of body-disownership, as will be demonstrated in the following section.7

5.5.1 Body-Disownership—What Does It Feel Like8 Jean Améry (1980), a Jew who participated in the organized resistance against the Nazi occupation in Belgium, was caught and tortured by the German Gestapo and spent several years in concentration camps (Auschwitz, Buchenwald, and Bergen-Belsen). In his book At the Mind’s Limit, he describes what it is like to be tortured. He begins with a general description:

6 Note that such a situation can result from a change in the numerator, the denominator, or both, though in each case the phenomenology is different. 7 For a full explanation of why Jean Améry was selected as a case study, see Appendix 1 8 This entire section is written in the masculine because it refers to Jean Améry’s testimony. 92 Y. ATARIA

What was inficted on me in the unspeakable vault in Breendonk was by far not the worst form of torture. No red-hot needles were shoved under my fnger- nails, nor were any lit cigars extinguished on my bare chest. What did happen to me there I will have to tell about later; it was relatively harmless and it left no conspicuous scars on my body. And yet, twenty-two years after it occurred, on the basis of an experience that in no way probed the entire range of possibilities, I dare to assert that torture is the most horrible event a human being can retain within himself. (Améry, 1980, p. 22, my emphasis)

The reason for this, according to Améry, is that from the very frst blow the prisoner understands that he is totally and absolutely helpless. As we saw, helplessness causes the feld of action to shrink. While being tortured, the victim understands that no one in-the-world will come to his rescue:

The frst blow brings home to the prisoner that he is helpless, and thus it already contains in the bud everything that is to come. One may have known about torture and death in the cell, without such knowledge having possessed the hue of life; but upon the frst blow they are anticipated as real possibilities, yes, as certainties. They are permitted to punch me in the face, the victim feels in numb surprise and concludes in just as numb certainty: they will do with me what they want. Whoever would rush to the prisoner’s aid-a wife, a mother, a brother, or friend-he won’t get this far. (p. 27)9

Torture causes a severe sense of both practical and existential helplessness. The victim no longer belongs-to-the-world and is unable to be in-the-world again because to do so requires placing trust-in-the-world:

I don’t know if the person who is beaten by the police loses human dig- nity. Yet I am certain that with the very frst blow that descends on him he

9 Whereas the former quotation tended towards a subjective description of an experience from within (albeit in a limited manner), in contrast this one offers insights more than a subjective portrayal of experience. It is vital to create this distinction because among trauma victims we must emphasize the movement between 1PP and 3PP. Clearly, that which is defned here as “a subjective experience” is also infuenced by the theoretical approach, while the theoretical approach is infuenced by Améry’s experiences. Moreover, at times, Améry moves between the subjective and the theoretical. Despite this, it seems appropriate to attempt to distinguish between the two kinds of descriptions. 5 THE COMPLEX RELATIONS BETWEEN SA AND SBO DURING TRAUMA … 93

loses something we will perhaps temporarily call “trust in-the-world.” Trust in-the-world includes all sorts of things: the irrational and logically unjusti- fable belief in absolute causality perhaps, or the likewise blind belief in the validity of the inductive inference. (p. 28, my emphasis)

During torture, the boundaries of the body are desecrated and shattered, the self breaks down, and the cruelty of the world penetrates deep inside, profoundly changing the very structure of the sense of self.

The boundaries of my body are also the boundaries of my self. My skin surface shields me against the external world. At the frst blow, however, this trust in-the-world breaks down. The other person, opposite whom I exist physically in-the-world and with whom I can exist only as long as he does not touch my skin surface as border, forces his own corporeality on me with the frst blow. He is on me and thereby destroys me… Certainly, if there is even a minimal prospect of successful resistance, a mechanism is set in motion that enables me to rectify the border violation by the other person. For my part, I can expand in urgent self-defense, objectify my own corporeality, restore the trust in my continued existence. If no help can be expected, this physical overwhelming by the other then becomes an existential consumma- tion of destruction altogether. (p. 28, my emphasis)

This process renders the tortured individual absolutely helpless, totally lacking a sense of agency. During torture, the body breaks down and the sense of self is reduced to the boundaries of the body-as-object. This existential helplessness is far from temporary; indeed, it changes the individual’s existential experience over the long term. The tortured individual is present in a world in which he does not believe; he simply does not understand what it means to be human. Let me explain this notion further. The dual structure, being at once both a subject and an object, stands at the heart of being human. Indeed, as we have seen, Merleau- Ponty (1964) argues that the “human body is present when, between the see-er and the visible, between touching and touched, between one eye and the other, between hand and hand a kind of crossover occurs” (p. 163). When this dual structure breaks down, as it does during severe and ongoing trauma, the human body can no longer exist. Thus, not only does the tortured individual cease to be a human being; he also fails to understand what it means to be human. 94 Y. ATARIA

Essentially, when we are separated from everything that makes us human, we are left only with instinctive bitterness. As Shalamov,10 a Gulag survivor, stresses in his story “Sententious” (1994):

I had little warmth. Little fesh was left on my bones, just enough for bitterness – the last human emotion; it was closer to the bone... What remained with me till the very end? Bitterness. And I expected this bitterness to stay with me till death… Bitterness was the last feeling with which man departed into non-being, into the world of the dead.

This insight is extremely important. After being broken into pieces, we are reconstructed based on bitterness and hate. In turn, if those who have been totally broken are bitter at the very core, we can understand why and how body-disownership can develop. Indeed, in this point, body-disownership, on the one hand, and lack of SBO, on the other hand, can no longer described as similar phenomena. The life of a torture victim is reduced not merely to the body-as- object but specifcally to one point of maximum pain. During this process, the sense of subjectivity dwindles to a singular point of pure suffering. This singular point is not abstract but rather manifests itself in the body, in some cases even at a certain location in the body. Thus, the body becomes totally distorted, as does the world:

In the bunker there hung from the vaulted ceiling a chain that above ran into a roll. At its bottom end it bore a heavy, broadly curved iron hook. I was led to the instrument. The hook gripped into the shackle that held my hands together behind my back. Then I was raised with the chain until I hung about a meter over the foor. In such a position, or rather, when hanging this way, with your hands behind your back, for a short time you can hold at a half- oblique through muscular force… All your life is gathered in a single, limited area of the body, the shoulder joints, and it does not react; for it exhausts itself completely in the expenditure of energy. But this cannot last long… I had to give up rather quickly. And now there was a crackling and splintering in my shoulders that my body has not forgotten until this hour. The balls sprang from their sockets. My own body weight caused luxation; I fell into a void and now hung by my dislocated arms, which had been torn high from behind and were now twisted over my head. (Améry, 1980, p. 32, my emphasis)

10 For a more detailed explanation of the use of sources to describe this experience, see the Appendices. It appears almost impossible to fnd descriptions of such experiences that are lacking in pathos. Shalamov’s book is an exception that provides an exact and in-depth description. 5 THE COMPLEX RELATIONS BETWEEN SA AND SBO DURING TRAUMA … 95

Indeed, when the tortured individual cannot separate himself from his body, he undergoes a process of absolute reduction to the body-as- object. This is the critical breaking point at which the tortured individual begins to relate to his own body as the enemy. The tormentor is no longer responsible for the victim’s pain; rather, the victim’s own body is responsible:

Whoever is overcome by pain through torture experiences his body as never before. In self negation, his fesh becomes a total reality. Partially, torture is one of those life experiences that in a milder form present themselves also to the consciousness of the patient who is awaiting help, and the popular saying according to which we feel well as long as we do not feel our body does indeed express an undeniable truth. But only in torture does the transformation of the person into fesh become complete. (Améry, 1980, p. 33, my emphasis)

When unable to disconnect from the body during torture, we are being reduced to the body-as-object. Jorge Semprún, who was arrested in 1943 by the Gestapo and deported to Buchenwald concentration camp, describes this process as follows:

My body was suffocating, becoming mad, begging for mercy, ignobly. My body asserted its independent presence in an uprising from my gut that pre- tended to reset me as a moral entity. It beseeched me to give into the torture, it demanded that. To come out a winner in this battle with my body, I had to give in, to control it, while abandoning it to the threats of pain and humiliation. (Semprun, 1998, p. 148, my emphasis)

In such extreme situations, nothing remains of the sense of self except the body as a dead object. In terms of the SA:SBO ratio, we may say that whereas the SA has dropped almost to nothing, the SBO has not weakened. As noted, for an individual to maintain control in the face of a weakened SA, the SBO must likewise weaken. In Améry’s case, his SBO did not decline, resulting in a fundamental gap between SA and SBO, with the SA:SBO ratio approaching zero. The outcome of such a situation can be devastating: the victim becomes his own enemy. To understand the logic leading individuals to treat themselves as their own enemy, let us return to Améry’s statement: Those who are unable to separate from their body experience the body in a way they never experienced it before. The tortured individual is reduced to this shattered body 96 Y. ATARIA and unable to separate from it. The victim is nothing more than a body- as-object, which has become the cruelest enemy—a tool that creates pain. Dissociation is one method of coping. If dissociation fails, however, the only remaining alternative is to attack the body. Yet these alternatives are nothing more than two sides of the same coin. As noted, this process begins when the sense of self (The sense of self is not just one thing but rather a whole structure—based on different kinds of components, elements, forces and interactions) is completely reduced to the body: “Frail in the face of violence, yelling out in pain, awaiting no help, capable of no resistance, the tortured person is only a body, and nothing else beside that” (Améry, 1980, p. 33, my emphasis). Yet because the body is experienced only as total and absolute pain, the sense of self is reduced to pain, as Améry describes:

In the end, we would be faced with the equation: Body Pain Death, and = = in our case this could be reduced to the hypothesis that torture, through which we are turned into body by the other, blots out the contradiction of death and allows us to experience it personally. (p. 34, my emphasis)

To improve our understanding of this process, we must realize that under such circumstances the only reality is the reality of the torture chamber. The tortured individual thus builds a new world populated by only two types of people—the torturers and the tortured, the strong and the weak, and ultimately the righteous and the sinners or the good and the bad. In a helpless and shattered world, when all that remains is the agonized body, the one holding the power is also the one who is morally right, deserving and representative of the ultimate good. Indeed, under such circumstances, the tortured individual admires the torturer:

There were moments when I felt a kind of wretched admiration for the ago- nizing sovereignty they exercised over me. For is not the one who can reduce a person so entirely to a body and a whimpering prey of death a god or, at least, a demigod? (p. 36, my emphasis)

At such extreme moments, tortured individuals can even identify with the torturer and can identify their own weak and feeble body as the source of wretchedness, evil, and weakness. To rephrase this notion, the victim becomes detached from the body-schema and exists at the body-image level only, thus embracing the persecutor’s point of view. While the victim gains control, the price is the loss of SBO. 5 THE COMPLEX RELATIONS BETWEEN SA AND SBO DURING TRAUMA … 97

Consequently, the SA:SBO ratio now approaches infnity. In the process, the tortured body becomes the source of all troubles:

there are situations in life in which our body is our entire self and our entire fate. I was my body and nothing else: in hunger, in the blow that I suffered, in the blow that I dealt. My body, debilitated and crusted with flth, was my calamity. (pp. 90–91, my emphasis)

At this point, humanity loses all meaning. The tortured individual is absolutely alienated from the world and totally accepts that those in power are also right and more deserving.

If from the experience of torture any knowledge at all remains that goes beyond the plain nightmarish, it is that of a great amazement and a foreignness in-the-world that cannot be compensated by any sort of subsequent human communication. Amazed, the tortured person experienced that in this world there can be the other as absolute sovereign, and sovereignty revealed itself as the power to infict suffering and to destroy. (p. 39, my emphasis)

Améry’s suicide is not an accident but rather, a result of a deep sense of hostility toward his own body—as Schilder (1935) stresses: “When the whole body is flled with pain, we try to get rid of the whole body” (p. 104). Indeed, the long-term outcomes of body-disownership are devastating. One direct outcome of this destructive mechanism is self-injuring behavior in the broadest sense. In the next chapter we explore the link between severe and ongoing trauma, body-disownership, and self-injuring behavior.

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Scarry, E. (1987). The body in pain: The making and unmaking of the world. New York: Oxford University Press. Schauer, M., & Elbert, T. (2010). Dissociation following traumatic stress: Etiology and treatment. Zeitschrift für Psychologie/Journal of Psychology, 218(2), 109–127. https://doi.org/10.1027/0044-3409/a000018. Schilder, P. (1935). The image and appearance of the human body. New York: International Universities Press. Semprun, J. (1998). Literature or life (L. Coverdale, Trans.). New York: Penguin Books. Shalamov, V. T. (1994). Kolyma tales (J. Glad, Trans.). London: Penguin Books. Spiegel, D. (1997). Trauma, dissociation, and memory. Psychobiology of Posttraumatic Stress Disorder, 821, 225–237. Van der Hart, O., Nijenhuis, E., Steele, K., & Brown, D. (2004). Trauma- related dissociation: Conceptual clarity lost and found. Australian and New Zealand Journal of Psychiatry, 38, 906–914. https://doi.org/10.1111/ j.1440-1614.2004.01480.x. Van der Kolk, B. A. (1987). Psycological trauma. Washington, DC: American Psychiatric Press. Van der Kolk, B. A., & Saporta, J. (1991). The biological response to psychic trauma: Mechanisms and treatment of intrusion and numbing. Anxiety Research, 4(3), 199–212. Van der Kolk, B. A., & Van der Hart, O. (1989). Pierre Janet & the break- down of adaptation in psychological trauma. American Journal of Psychiatry, 146(12), 1530–1540. https://doi.org/10.1176/ajp.146.12.1530. Van der Velden, P., & Wittmann, L. (2008). The independent predictive value of peritraumatic dissociation for PTSD symptomatology after type I trauma: A systematic review of prospective studies. Clinical Psychology Review, 28, 1009–1020. CHAPTER 6

Self-Injuring Behavior

6.1 self-Injuring Behavior: A Brief Introduction Nock (2010) defnes deliberate self-injury as causing of intentional and direct harm to body tissue without suicidal intent. However, not all scholars accept this defnition. The inability to provide an unequivocal defnition has led to various conceptualizations, which in turn employ a variety of terms for seemingly similar phenomena, including mod- erate self-mutilation, deliberate self-harm, self-wounding, and even para-suicidal behavior. This diverse terminology is not merely a matter of semantics but rather reveals theoretical disagreement concerning the nature of this phenomenon or set of phenomena. Moreover, the existence of a range of different terms for this phenomenon signifes a deep-rooted diffculty in defning this type of behavior. For example, smoking can be considered a form of deliberate self-harming behavior, yet even if smoking and self-cutting, which is the most common type of self-injury, are on the same spectrum, they cannot be deemed the same phenomenon. Yet nevertheless, Nock (2010) insists that in essence all these phenomena share one common feature: “They all represent attempts to modify one’s affective/cognitive or social experience, they cause bodily harm, and they are associated with other forms of mental disorders (e.g., depressive, anxious, externalizing disorders)” (p. 343). Self-injuring behavior (SIB) is considered a coping mechanism. Thus, individuals who engage in this kind of behavior usually feel a sense of calm and control following an episode of self-injury; in addition, their

© The Author(s) 2018 101 Y. Ataria, Body Disownership in Complex Posttraumatic Stress Disorder, https://doi.org/10.1057/978-1-349-95366-0_6 102 Y. ATARIA functional abilities often improve. In particular, those who engage in SIB report feeling safe from suicide. Sutton (2007) offers the following testimony to support this concept:

I understand that others will see self-harm as being destructive but for me at the time it was very much a means of survival. Although I agree the physical affect on my body was destructive, the temporary psychological relief was crucial to me, in that moment, for my survival. (p. 7)

Moreover, Stanley and her colleagues (1992) argue that “thoughts of death prior to self-mutilating need not be related to an intent to execute such thoughts via the ensuing self-injury; on the contrary, the self-mutilation could be aimed at relieving these, and other such unbearable, thoughts” (p. 151). Yet in more than 50% of cases, those who engage in SIB also present suicidal behavior. Moreover, SIB and suicide apparently share the same risk factors: “Histories of childhood physical and sexual abuse, as well as parental neglect and separations, are strongly correlated with a variety of self-destructive behavior in adulthood, including suicide attempts and cutting” (Van der Kolk, Perry, & Herman, 1991, p. 1669). Furthermore, scholars contend that “suicide attempts and nonsuicidal self-injury apparently involve similar and multiple motives” (Brown, Comtois, & Linehan, 2002, p. 201). These fndings require further explanation. Studies have proposed that subjects who engage in SIB and also attempt suicide “tend to do so at times when they are not actively self-harming and by engaging in behaviors that are not classifed as deliberate self-harm” (Gratz, 2003, p. 193). However, while in the short-term SIB reduces negative emotions, such as anger, depression, loneliness, and frustration, in the long term, besides the sense of relief we also encounter “emotions such as guilt, shame, and disgust,” which in turn, “increased substantially following self-harm” (Laye-Gindhu & Schonert-Reichl, 2005, p. 454). Although following SIB an individual may potentially feel an immediate decrease tension, in the long-term each case of SIB increases the tension to the point that it becomes overwhelming or intolerable. The subject thus feels a need to reactivate the same SIB mechanism, resulting in an infnite escalation loop. Moreover, as Nock (2010) suggests, similarly to the learned helplessness mechanism, SIB is also a learned mechanism, forcing the self-harmer to heighten the level of pain in each and every 6 SELF-INJURING BEHAVIOR 103 new episode in order to gain relief. Indeed, some argue that “SIB results from an ‘auto-addictive’ mechanism, whereby the self-injurious behavior, such as wrist cutting, elevates levels of endogenous opiates and requires repetition of the behavior to maintain the resulting ‘high,’” specifcally a “dysregulation in particular neuroendocrine systems, which result in a predisposition for developing auto-addictive behaviors, such as SIB” (Kemperman, Russ, & Shearin, 1997, p. 154). This notion goes hand in hand with fndings which indicate that those who engage in SIB usually report experiencing little or no pain during episodes of self-injury (Nock & Prinstein, 2005). If this is indeed the case, then while engaging in SIB, the subject is eventually forced to increase the level of pain until real damage is inficted. In this sense, SIB can be positioned along the same spectrum as suicidal behavior: “a spectrum of self-harm behaviors with completed suicide at one extreme end of the spectrum to less damaging behaviors at the other” (Stanley et al., 1992, p. 149). Therefore, unsurprisingly, a study within a community of adolescents found that “one-quarter of the self-harmers in the study also report a prior suicide attempt and a majority indicated suicidal ideation” (Laye-Gindhu & Schonert-Reichl, 2005, p. 455). Overall, instead of defning SIB as intentional and direct injury to one’s body tissue without suicidal intent, I prefer to use Herpertz’s (1995) defnition: deliberate destruction of body tissue without conscious suicidal intent. The high incidence of suicide attempts among individuals who engage in SIB can be explained by the fact that both phenomena share “common underlying psychological and/or biological characteristics and, therefore, are likely to co-occur” (Stanley et al., 1992, p. 152). In both cases, anger and aggression turn inward, and the subject identifes the body as the cause of suffering. We can thus argue that “both suicidal and self-mutilating acts comprise deliberate physically self-injurious behaviors that can be conceptualized as manifestations of impulsive aggression towards the self.” Thus, “while suicidal behavior appears to be the most severe form of self-harm, self-mutilation can be viewed as a less serious form of self-harm” (p. 153).

6.2 self-Injuring Behavior as a Coping Mechanism Among other things, SIB is “a vehicle for punishing oneself for some perceived wrongdoing or responding to general self-hatred or self- deprecation” (Nock, 2010, p. 352). Thus, SIB appears to be strongly 104 Y. ATARIA associated with an individual’s negative core beliefs regarding the self, which, in turn, “become interpreted as the ‘absolute truth’” (Sutton, 2007, p. 177). Yet many believe that self-injuring behavior (SIB) should be viewed as a maladaptive coping mechanism born out of severe and prolonged trauma (trauma type II) or any other event generating a “deep-rooted sense of powerlessness” (Sutton, 2007, p. 6). Sutton further suggests that SIB is a pain exchanger, converting an invisible yet overwhelming emotional pain into visible physical wounds, making it easier to confront the evident injury. Along the same lines, SIB is considered an “effective strategy for ‘battening down the emotional hatches’ and safeguarding oneself from the likelihood of an overwhelming psychological storm” (Sutton, 2007, p. 7). This notion is compatible with Bennum’s (1984) anxiety model: When adaptive tools to deal with tension during stressful life events are lacking, feelings of tension gradually rise, reaching an intolerable level. In order to reduce the tension, the individual adopts SIB as a tool for stress regulation and tension reduction. Favazza (1998) lends support to this model by demonstrating that those who engage in SIB usually report immediate relief following the act. Self-harmers are more likely to be emotionally distressed, have low self-esteem, engage in antisocial behavior, and report problems in controlling their anger, in addition to experiencing increased discomfort at their angry feelings. These fndings suggest that SIB is a tool providing relief from anxiety, feelings of guilt, loneliness, alienation, self-hatred, unpleasant thoughts and emotions, and depression. SIB offers release from anger and tension, enables the subject to externalize emotional pain, and provides a sense of security and a sense of control. It is a form of self-punishment, of setting boundaries with others, of eliminating depersonalization and derealization, of preventing fashbacks, and of putting a stop to racing thoughts (Gratz, 2003). Similarly, according to Nock (2010), self-injury “functions as an immediately effective method of regulating one’s affective/cognitive experience and/or infuencing one’s social environment in a desired way” (p. 348). Others suggest that SIB should be treated as “a mechanism for regulating and coping with emotions” (Laye-Gindhu & Schonert-Reichl, 2005, p. 448). Nock proposes that SIB may result from a subject’s limited ability to confront challenging and stressful events in an adaptive way. Thus, self-injuring behaviors can be considered one form of maladaptive behavior, enabling the individual to regulate feelings in various situations, 6 SELF-INJURING BEHAVIOR 105

“as a result of the presence and interaction of earlier environmental and genetic factors” (Nock, 2010, p. 351). Yet signifcantly, the “notion that there may be ‘a gene for behaviors’ such as self-injury is unrealistic and inaccurate given the complex and multidetermined nature of both gene-behavior relations and of suicidal behaviors themselves” (Nock, 2010, p. 351). With regard to earlier environmental conditions, however, much evidence links childhood abuse with self-injuring behaviors.

6.3 siB: A Long-Term Reaction to Severe Trauma Although not always the case, almost every study of SIB identifes a history of child abuse, including sexual abuse, neglect, emotional abuse, physical abuse, and the like (Arnold, 1995; Favazza, 1989; Favazza & Conterio, 1988; Hawton, Rodham, Evans, & Weatherall, 2002; Van der Kolk et al., 1991). Thus, beyond any biological factor, signifcant childhood trauma constitutes the core of SIB and “the age at which trauma occurs plays a role in both the severity and expression of self-destructive behavior: the earlier the trauma, the more cutting” (Van der Kolk et al., 1991, p. 1667). It is commonly accepted that child abuse underlies various kinds of psychiatric mental disorders. This fnding is both unsurprising and insuf- fciently specifc. Indeed, Yates suggests (2009) that “specifc forms of maltreatment are differentially related to non-suicidal self-injury” (p. 119). In particular, sexual abuse, neglect, emotional abuse, and physical abuse should not be addressed as the same phenomenon but rather should be differentiated. However, as Gratz (2003) stresses, many studies fail to make such a distinction. Boudewyn and Liem (1995) examine the relationship between SIB and childhood sexual abuse. Their analysis includes separate exam- inations of loss, physical abuse, emotional abuse, and sexual abuse. Only childhood sexual abuse emerges as a signifcant predictor of SIB. Similarly, Gratz, Conrad, and Roemer (2002) contend that even after controlling for other variables, sexual abuse remains a major predictor of SIB among women, yet not among men. One explanation for this may be the female tendency to direct anger inward as opposed to the male inclination to direct anger toward an external source. In fact, physical abuse (in comparison with other variables) is associated with SIB for males, although no consensus has yet emerged concerning the nature of the relationship between physical abuse and SIB (Gratz, 2003). 106 Y. ATARIA

Scholars further suggest that “it is not simply the experience of sexual abuse but rather, specifc aspects of the experience that were associated with engaging in SIB” (Weaver, Chard, Mechanic, & Etzel, 2004, p. 570). Indeed, sexual abuse is not the only risk factor for SIB. For instance, a study of a mixed clinical-community sample fnds that physical or emotional neglect are powerful predictors of SIB: “neglect became the most powerful predictor of self-destructive behavior” (Van der Kolk et al., 1991, p. 1669). Likewise, Dubo, Zanarini, Lewis, and Williams (1997) fnd that compared to childhood sexual and physical abuse, emotional neglect is the strongest predictor for SIB. That being said, Gratz (2003) argues that “there is some evidence that emotional neglect may be a signifcant predictor of deliberate self-harm, more closely related to this behavior than physical neglect” (p. 196). Interestingly, as in the case of sexual abuse, gender differences are evident in the relationship between emotional neglect and SIB (Gratz et al., 2002).

6.4 siB and Traumatic Memories A vast majority of those who engage in SIB were victims of childhood abuse. In such cases, as well as other instances of prolonged and severe traumatic experiences, traumatic memories play a major role. Considering this, I propose that SIB is a coping mechanism enabling survivors to deal with their traumatic memories. Let me begin by defning the nature of the traumatic memory.

6.4.1 The Nature of the Traumatic Memory Posttraumatic individuals tend to report remembering the traumatic experience all too well. At the same time, there are undoubtedly some fundamental defcits in the structure of the traumatic memory as an autobiographical memory. Note, however, that there is no real contradiction here: As a constructed story, the traumatic memory is indeed poorly remembered, yet at the same time the traumatic experience leaves a scar on the bodily level. These bodily memories refer to somatic memories that are encoded and stored implicitly. Memories of this kind are not easily removed. We thus suggest that whereas one kind of story—semantic and explicit, yet poorly remembered—exists on the level of the autobiographical self, a different kind of “story,” one that is neither semantic nor declarative but remembered all too well, exists on the bodily level—at the 6 SELF-INJURING BEHAVIOR 107 body-schema level. The subject remembers the sensory and emotional elements of the traumatic experience yet lacks the linguistic/contextual factor: “traumatic ‘memories’ consist of emotional and sensory states, with little verbal representation” (Van der Kolk & Fisler, 1995). As Brewin and Holmes (2003) note, “poor incorporation of the event into the more general part of the autobiographical database is thought to result in a memory that is hard to retrieve intentionally, that is experienced as being without a context, and that is easily triggered by physically similar cues” (p. 366). Indeed, smells, sights, sounds, and other stimuli similar to those that occurred during the traumatic event can trigger the bodily somatic memory and cause the traumatic memories to resurface. As Ehlers, Hackmann, and Michael (2004) emphasize, the subject is aware of some of these, but completely unconscious of others. Intrusive memories may assume the form of nightmares and fashbacks containing rich multimodal mental images with highly detailed sensory impressions of the traumatic event (Krans, Näring, Becker, & Holmes, 2009). These images are accompanied by a strong bodily experience that causes the posttraumatic subject to re-experience the traumatic event in the here-and-now. Indeed, for “people with posttraumatic stress disorder, remembering trauma feels like reliving it” (McNally, 2003, p. 105). Ehlers and Clark (2000) maintain that intrusive memories appear due to a fragmented encoding during the traumatic event and “can be understood as warning signals, stimuli that predicted the onset of the trauma” (Ehlers et al., 2004, p. 411). Intrusive memories may be triggered by general traumatic memories. This is not common, however, since intrusive memory and episodic memory are not the same, but rather depend “on the retrieval route and on different memory processes” (p. 408). The cues that trigger intrusive memories are mainly “temporally associated with the event” (p. 406), and not contextual: “The involuntary reexperiencing of the traumatic event is triggered by a wide range of stimuli and situations,” many of which “do not have a strong semantic relationship to the traumatic event, but instead are simply cues that were temporally associated with the event” (Ehlers & Clark, 2000, p. 325). Moreover, intrusive traumatic memories remain frozen in time even years after the traumatic event, involve strong physical responses, and are perceived as a current threat (Ehlers & Clark, 2000; Ehlers et al., 2004). Keeping this in mind, let us examine two case studies regarding women who endured prolonged and ongoing trauma: Jill and Linda. 108 Y. ATARIA

6.4.2 SIB as a Coping Mechanism for Traumatic Memories During therapy, Jill confronted images of her abuse at the hands of her father, yet could not recall undergoing these experiences. As the course of therapy advanced, these images become more lifelike and turned into real memories of her abuse, accompanied by physical pain. As the memories become more vivid, Jill’s need for SIB increased dramatically, to the point that she lost control. She felt that SIB enabled her to deal with the unbearable memories. Let us take a closer look at Jill’s testimony:

Until four years ago I had not actually hurt myself physically and deliberately by cutting. Then suddenly I began to experience overwhelming urges to cut myself with razors, knives or anything sharp and pointed enough to cause me suffcient pain to block out the inner pain and turmoil that was driving me mad inside. A food of recovered memories of years of sexual and emotional abuse by my father, starting from when I was as young as four, was the catalyst for my ‘cutting’. Time after time I tried to blot away the ‘horrid- ness’ inside me which to this day feels as scary as it did then; as well, as then, there seemed to be no relief from it. Until that is the day when I suddenly found that by cutting, scratching, tearing or stabbing with knives, scis- sors, razors, anything - I could momentarily blot out the hurt inside of me. My cuts dug anywhere but especially in those very private places where the pain and the memory is the worst. It felt that by concentrating very intensely on creating this other hurt I was able to blot out the deeper and more terrible pain: the relief was only momentary, but so, so welcome. For that very brief time I felt in control and had gained some temporary release from the constant jangling tension, terrifying panic and searing pain inside my head and body. (Sutton, 2007, pp. 160–161, my emphasis)

Clearly, by adopting SIB, Jill attempted to reduce the stress accompa- nying her traumatic memories. The bodily traumatic memories were so alive, causing Jill to feel that by cutting her body, the pain could leak out of her. Moreover, by cutting herself, Jill may have been trying to dissociate in order to escape the pain, that is, to reduce her SBO. While this classic case gives us some insight regarding how SIB can regulate traumatic memories, the analysis does not capture the complexity of Jill’s behavior. Jill testifes that she cut herself especially in those very private places where the pain and the memory are the worst. A study among adult survivors of childhood sexual abuse reveals that vaginal lacerations are the most common form of SIB (Weaver et al., 2004). According to Yates, 6 SELF-INJURING BEHAVIOR 109

“sexual abuse localizes trauma squarely in the domain of the body, which later serves as the target of self-harm” (Yates, 2004, p. 44). Consequently, traumatic memories are not merely localized in the body metaphorically but rather are situated in the body de facto and at specifc locations. Jill cut herself in areas specifcally linked to her traumatic experience. By doing so, she attempted (a) to cut out or extract the actual memories from her body and (b) to attack the trauma itself. Let us examine this notion further. Jill’s body constituted the source of her traumatic non-verbal memories; it was the source of her pain; and it is her enemy. Hence, by attacking her body, she sought to eliminate the pain. Indeed, it has been suggested that SIB represents “a deliberate bodily attack on the trauma” (Dyer et al., 2009, p. 1110). We thus propose that Jill developed disownership toward a specifc part of her body, just as disownership develops toward a limb in cases of BIID. In cutting her body, Jill treats it as-an-object and as a tool that creates pain. Thus, she adopts a 3PP medical–surgical perspective toward her body at the expense of the 1PP. Jill can no longer experience the world from within her body, that is, from an egocentric perspective: Only when she treats her body-as-an-object can she control it from the outside. Indeed, Jill’s ability to be present in-the-world depends on her ability to reject 1PP in favor of 3PP. Yet this strategy has its price: In the process of adopting the 3PP perspective, not only does Jill adopt the point of view of the one who generated the trauma but also his very ideology.1 Jill’s trauma has been burned into her body-schema. Thus, like Ian Waterman, she exists only at the body-image level: the body she is abusing is in effect not her body, but rather the body-as-object. Continuing this line of thought, de Vignemont (2016) claims that people who harm their own body and do not feel any pain can tell themselves this is so because this is not their own body. Indeed, it cannot be their body if they do not feel pain. Self-harm can therefore serve as confrmation that this is not my body. Jill seems to be saying: If this were my body I surely would feel whether I was cutting it. Therefore, since I don’t feel anything, apparently it is not my body. This explanation resembles cases of somatoparaphrenia, in which the inability to control a limb causes the individual to feel that this limb is not her own.

1 Certainly, the use of the word “ideology” in the case of a father raping his daughter is problematic. Yet from the victim’s perspective, this is an ideology resembling that of other cases of ethnic-based trauma. 110 Y. ATARIA

In conclusion, it seems that Jill is affected by defcits at the body- schema level, located in a specifc area. Consequently, Jill has developed localized body-disownership. We will now proceed to the case of Linda, another subject who engaged in self-injury. Linda describes her childhood in the following manner:

Physical beatings, sexual intercourse, oral and anal sex were part of my everyday existence. Night after night I would lie awake in my bed dreading the sound of those all too familiar footsteps on the stairs… As if this wasn’t enough to endure, he also allowed his friends to abuse me… He totally ignored my des- perate pleas for help, encouraging his friends to have oral and anal sex with me. There were many times when I just wished I was dead… If I protested he would run a bath of freezing cold water and force me to get into it naked. He would then hold me under the water until I submitted to his perverted desires. I will never understand why my mother didn’t stop him. Often I would scream out in terror, but all she did was stand and watch, or walk away… When I was six the pain became too much to bear. I hit the wall in my bed- room with my fst. Strangely, this brought a little bit of relief. After that I began hurting myself in various ways. … When I was ffteen my Dad got me pregnant and I gave birth to twins – a boy and a girl. Tragically my little girl died at birth due to a deformity, but my son was a beautiful and healthy baby. I went to stay with friends, and one day, when I had popped out, my father came and took my son away… I have never seen my son again to this day. After this, the emotional pain overwhelmed me and I couldn’t stop self-harming. I cut my wrists, drank myself into a stupor and took pills…. I ended up in a psychiatric unit where I received little sympathy or understanding… From the hospital I was referred to a hostel. Here I made friends with one of the male residents, only to be raped by him and three of his friends when we were out one evening… As the pain grew and grew inside me, the need to self-harm increased… In 1989 I married again. I have two children, a little boy aged two, and a little girl aged four. The frst two years of the marriage were great, but following the birth of my son things started going wrong again. When he was just three months old I tried to suffocate him. Post-natal depression was diagnosed, but I soon realised that it was not this at all – it was the emotional pain I was in due to the traumas I had suffered at the hands of my father and others. For over twenty years all these horrifc memories had been pushed into the dark recesses of my mind, but somehow the birth of my son rekindled some of these unbearable and terrifying memories. (Sutton, 2007, pp. 164–166, my emphasis)

Not only was Linda raped and humiliated by her father, but her mother also cooperated with him, or so it seemed to Linda. She developed SIB 6 SELF-INJURING BEHAVIOR 111 at the age of six as a way to ease her pain. The birth of her son triggers unbearable memories—probably a reminder of her frst son, who was taken from her—leading her once again to engage in SIB. Linda’s SIB is a reaction to the traumatic memories accosting her. We can view Linda’s SIB as regulatory in nature, although this explanation alone is unsatisfactory. The notion of structural dissociation as a possible outcome of severe trauma is vital in understanding Linda’s behavior. This concept will be discussed in more detail in Chapter 7, but is introduced here for the purposes of the present discussion. In brief, survivors of type II trauma sometimes develop two different and contradictory personalities, each unconscious of the other. One is the apparently normal personality (ANP), which has apparently moved on and denies any connection to the traumatic memories. The other is the emotional personality (EP), stuck within the traumatic moment. With this in mind, let us return to Linda’s case. According to one possible interpretation of Linda’s behavior, her childhood experiences may have led her to develop a deep sense of self-hatred; consequently, by injuring herself, she is simply implement- ing these basic feelings. However, this behavior can also be explained by applying the terminology of ANP/EP: Linda’s emotional personality has become a source of threat and her apparently normal personality thus views the emotional personality as the enemy and attempts to destroy it. After her marriage, Linda’s apparently normal personality dominated her life, yet her son’s birth awakened the emotional personality rooted within the bodily memory of trauma. To survive and thwart the loss of another son, Linda’s only alternative is to dispose of her emotional personality. Unable to confront her overwhelming memories, Linda has no choice but to terminate and eliminate the source of her pain—her own body. She does not seek to commit suicide (maybe) because she wants to raise her two children, yet she must eliminate her traumatic past. This is no easy task because her traumatic memory is burned deeply into her body at the body-schema level. Hence, her only alternative2 is to destroy her body as the source of pain and suffering. When the living-body becomes a living memory of the traumatic past, survivors may develop a strong belief that if only they can dispose of their own body, they will be able to recover. Similarly, in the case of

2 As was noted, at a certain stage, she tried to kill her own baby. It appears that turning the anger inward also serves to protect the baby. 112 Y. ATARIA

BIID, the individual believes that the only way to get rid of the unbearable feelings is to dispose of the disowned limb.

6.5 siB as a Means of Communication Even though SIB can signal poor communication abilities and an inability to tackle social problems, it is nevertheless a means of communicating with others and even of solving social problems. SIB is a bodily language and, in the absence of any other alternative, becomes the only possible language. As Nock (2008) notes: “When language fails to elicit a desired response people often resort (or ‘return’ from a phylogenetic perspective) to the use of physical behavior as a more powerful or forceful means of communication or infuence” (p. 159). This is especially true when an individual is unable to symbolize experience. Indeed, according to Yates (2004), “people who self-injure may use the body to symbolize affective experience because they lack the instrumental competence to process affective material cognitively via self-refection and mentalization” (p. 56). The following example shows that SIB is indeed a way of expressing bodily non-symbolic experiences which cannot be expressed in words.

Once the pain is on the outside, it brings temporary relief to the psychological anguish… I can “see” my hurt and give it a tangible reality, unlike the pain that can’t be seen on the inside. It brings me relief knowing that yes, I do hurt, even if no one else sees it. My “voice” is “heard” on my skin… it’s there, it’s real, and it hurts. (Sutton, 2007, p. 6)

This subsection attempts to explain how SIB can serve as a new type of bodily language. However, because, as already demonstrated, severe trauma forms the core of SIB, we must frst understand the fundamental problem involved in talking out the traumatic experience.

6.5.1 Bodily Trauma and the Need for a New Language The traumatic experience does not undergo high-level processing and does not become a symbol. Rather it remains sensory and somatic. Consequently, trauma does not turn into explicit memory but rather remains implicit and bodily, so that every movement, every posture, indeed the very presence of the body in-the-world, again recalls the 6 SELF-INJURING BEHAVIOR 113 traumatic experience. Thus, the body is a direct mediator of the traumatic experience and indeed the source of the trauma. The immediate implication of this bodily coding process during trauma is that it prevents the traumatic event from becoming a narrative: The memory remains physical and non-verbal. The inability to describe the trauma in words, to transform it into part of one’s narrative, is due precisely to the physical essence of trauma. Therefore, to allow victims to describe their experience during and after trauma, a new language is required, one in which language itself is rooted in—and constructed by—the body (Lakoff & Johnson, 1999; Merleau-Ponty, 2002; Varela, Thompson, & Rosch, 1991). If we adopt this notion, we must reconsider our very concept of the language used by survivors, particularly metaphors, that “comes from the body’s sensorimotor system” (Gibbs 2006, p. 99). Metaphors are tools via which we understand our surroundings; without them, the world is void of all meaning (Lakoff & Johnson, 1999). Trauma becomes burned into the body and creates a new bodily reality, yet language itself is incapable of grasping, expressing, and representing these radical changes and thus continues to represent the old reality, the “old body” prior to the trauma. The old metaphors become empty and meaningless and are unable to represent the new world. Thus, survivors cannot process their experiences from within their new traumatic body because they simply lack the metaphors to do so. As a result, a fundamental gap emerges between the familiar (yet alien to the posttraumatic survivor) language representing the previous systems of beliefs and the so-called new language which attempts to fnd a way to represent the unexpected world of trauma. Indeed, posttraumatic survivors fnd it impossible to describe their feelings leading them to search for and create new forms of expression (Ataria, 2017). Due to this linguistic foreignness, the traumatic event often remains outside the boundaries of the individual’s narrative, outside the autobiographical self. Indeed, traumatized survivors have lost (a) the ability to represent the traumatic experience to themselves, (b) the ability to create new metaphors that would endow their experience with meaning, (c) the belief that words mean anything at all, and (d) the ability to use words to express their feelings. Given that expressing ourselves is a basic need, survivors must fnd a new means of expression. In summary, it is possible to highlight two main malfunctions with respect to language and trauma: (a) The traumatic events are encoded in a way that renders them “inaccessible” to language and (b) the trauma 114 Y. ATARIA occurs at the level of language, so that language itself has been traumatized. As Hiroko puts it, “What words can we now use, and to what ends? Even: what are words?” (quoted in Treat, 1995, p. 27).

6.5.2 No One Believes Many survivors of the Nazi concentration camps testifed that they survived in order to tell the stories of those who perished. Thus, it is somewhat surprising that so many nevertheless chose3 to remain silent. One of the reasons for this is their deep sense of anxiety that no one would listen to them (Levi, 1959, 1993). Indeed, as Laub (1995) emphasizes, if a survivor tells the story and no one listens to it or believes it, this can constitute a second trauma. Some incest survivors who engage in SIB report this exact same experience. Sutton (2007) describes a case in which “a respondent reported that her disclosure to her mother that her father was abusing her had been met with denial and an accusation of False Memory Syndrome” (p. 151). Incest survivors who engage in SIB often mention the abuse itself along with the fact that their story was rejected: “I believe4 that the underlying reasons for my self-harm are because I was sexually abused by my father and brother—and because my family don’t know whether to believe me” (Sutton, 2007, p. 151). Survivors have clearly lost faith in language, both as a means of expression and as a way to communicate with others. However, strange and distorted it may sound, it appears that for victims of severe and prolonged trauma, SIB provides an opportunity to create a new language.

6.5.3 Breaking the Silence “Our view of man will remain superfcial so long as we fail to go back to that origin, so long as we fail to fnd, beneath the chatter of words, the

3 We are aware of the problematic nature of this word in this context. 4 We chose these and other similar testimonies, even though they are not compatible with the phenomenological approach. As Appendix 1 notes, the phenomenological approach rejects testimonies which attempt to provide explanations and justifcations (e.g., use of the word “because”). Nevertheless, it is diffcult to fnd phenomenological studies that examine self-injuring behavior. We therefore felt that compromise was necessary, at least on this point. 6 SELF-INJURING BEHAVIOR 115 primordial silence, and as long as we do not describe the action which breaks this silence. The spoken word is a gesture, and its meaning, a world.” (Merleau-Ponty, 2002, p. 214). Yates (2009) suggests that in some sense SIB is a “bodily based emotion regulation in the absence of adaptive integrative, symbolic and refective capacities” (p. 124). Severe and prolonged trauma, especially during childhood, “may leave affect to be symbolized through the body rather than language” (p. 125). This can lead to different kinds of bodily expressions, one of which is SIB. As McLane (1996) notes, SIB is the “voice on the skin” (p. 107); we should add that it is also the voice of the skin. In the case of severe trauma, silence is not a by-product of the event. Rather, it is the heart of the traumatic experience: “Speech is precisely what has been nullifed for the abuse victim. Even more, enforced silence has created what we might call an unreal unity to the victim’s body, life, and voice” (p. 110). As a result, victims fail to express their feelings. To break this deadly silence, victims must fnd a way to create a new language—a bodily kind of language:

Voice is silence, fesh is voice, skin is mouth and is pain and is numbness and is the expression of pain. Skin is the boundary whose self-breaking is forbidden, so that “normal” people can keep the inside and the outside distinct. But for the self-mutilator, inside and outside, pain and voice, must become one in the act of creating voice. For those who have no voice but of silence, extremity is the only possibility for the expression and ultimate ending of pain. (p. 117, my emphasis)

Bodily language does not require any intermediatory signs because it is prerefectively and directly connected to the moment of trauma. McLane offers the following example:

When hidden pain starts to speak, it will speak silently. Its voice may appear as a cut on the leg, a burn on the arm, skin ripped and scratched repeatedly. There will be no sound, not any, only unfelt and silent pain which makes its appearance in another pain, self-inficted, and when that second, col- lateral pain emerges, it will articulate in blood or blisters the open defnition you desire, although it may not be in a language you care to see. This, it says, is pain, and this is real in any language you care to speak. (p. 111, my emphasis) 116 Y. ATARIA

Indeed, we can argue that SIB is embedded within silence and is generated by silence:

The stopped voice becomes a hand lifting knife, razor, broken glass to cut, burn, scrape, pop, gouge. The skin erupts in a mouth, tongueless, tooth- less. A voice drips out, liquid. A voice bubbles out, fuid and scabby. A voice sears itself or a moment, in fesh. This is a voice emerging on the skin, a mouth appearing on the skin. The body which could not be air upon the larynx becomes the stroke of a razor on the breastbone or of a red-hot knife-tip upon the wrist. (p. 114, my emphasis)

SIB appears to constitute a unique way not only of expressing the silence but in fact of talking from within the silence, yet without breaking it:

This hand is silent in a way that even the wounded fesh is not. It is silent because it is whole, it has not even a mark that could stand for a voice or a word. But it speaks: in action, not in being acted upon. Though it is silent, action is its voice, just as the diaphragm lungs larynx sinuses tongue palate are in their own way silent, yet are the speaking itself. They are not the voice emerging from the mouth, the carnal sound, but push pulse curve expand contract; they are the ripple of fesh culminating in noise. This hand holding the knife is silent in action, loud in the voice it produces. (pp. 112–113, my emphasis)

Trauma shatters the very essence of a predictable world. Even worse, it creates a new kind of horrifying logic. In-the-world of trauma, the victim has no power over outcomes. The world of trauma is a world of pain without explanations, a world of brutality without causality. Nevertheless, victims of severe trauma sometimes feel at-home only within the traumatic world because they have learned how to function solely within this chaotic environment. The ordinary language and laws of daily life are irrelevant to the world of trauma. Hence, victims try to create a language that enables expression yet at the same time remains within the boundary of trauma. They seek to invent a language that represents their own inherent paradox: Victims want to live, yet they have deeply internalized the notion that they do not deserve to do so. When a victim is raped by her father, for instance, she sometimes feels she received what she really deserved. Thus, SIB perfectly represents the victim’s inner paradox. She seeks to take control over her life using the same method of pain and self-destruction with which she is so familiar: “This voice of action speaks, saying, ‘Destruction.’ ‘I cannot be stopped.’ Saying, ‘I will end the pain, even if in other pain.’ ‘I can act.’ Saying, ‘I exist’” (p. 113). 6 SELF-INJURING BEHAVIOR 117

SIB allows the victim to create some kind of order in a chaotic world. Umans, for example, stresses that at least while engaging in SIB, she knows where it hurts and why it hurts:

1 don’t enjoy the pain, but I don’t mind it either: it’s just a step in the process… It seems to be about attention and focus. The violence I infict on my hands and forearms is visible: I can see where the damage is, and know why. Then for a while I don’t have to mess with the mysterious physical and psychic sore spots. (Umans, 1992, p. 7)

In many cases, the victim does not become completely mute. She can talk, but her words are not connected with the traumatic experience. This is part of the victim’s structural dissociation. The apparently normal personality continues to talk, though it says nothing, while the emotional personality, frozen in the moment of trauma, lacks the ability to use words and hence fnds expression in bodily gestures such as SIB, creating a new world of meaning.

6.6 siB as a Tool for Managing Dissociation As was noted, SIB is strongly associated with childhood trauma (Nock, 2010; Sutton, 2007) and, in turn, it is well documented that severe and ongoing childhood trauma goes hand in hand with dissociation—a defense mechanism activated during trauma, as described in detail in Chapter 7. Over the long term, however, the dissociative mechanisms which are effective for an abused child can result in a conditioned response to stressful situations. Van der Kolk et al. (1991) claim that “ongoing dissociation is directly associated with cutting” (p. 1669). Indeed, current studies reveal that in many cases those who engage in SIB report dissociative processes such as depersonalization, decreolization. Sutton (2007), for instance, describes the following case: “Cutting feels like I’m watching from somewhere else although it is my hands doing the cutting” (p. 215). Furthermore, a study among a group of psychiatric inpatients with dissociative disorders found that 86% engage in SIB (Saxe, Chawla, & Van der Kolk, 2002). Similarly, according to Herman (1992b), “survivors who self-mutilate consistently describe a profound dissociative state preceding the act,” suggesting that, “depersonalization, derealization, and anesthesia are accompanied by a feeling of unbearable agitation and a compulsion to attack the body” (p. 109). Indeed, a vast majority of those who engage in self-harm 118 Y. ATARIA demonstrate obvious dissociative symptoms. Prior to the SIB, they report feeling emotionally numb, dead inside, and detached from themselves; during the act, they claim to feel almost no physical pain; and following the act, they report feeling more alive and in addition more grounded. Sometimes, however, the SIB itself allows individuals to generate a dissociative mechanism. In these cases, they feel the pain which, in turn, allows them to dissociate. These phenomena of facilitating and diminish- ing dissociation are two sides of the same coin. Let us elaborate. Reports describe depersonalization as extremely unpleasant and frightening (Simeon & Abugel, 2006). Those who engage in SIB report that the very act of self-injury allows them to feel once again, to be part of the world, to gain a sense of belonging. Thus, as illustrated in the following example, SIB can eliminate depersonalization: “You see things, but they are so far away—and you can’t touch them because they are just too far. Cutting brings things back to where they should be” (Sutton, 2007, p. 216). In such cases, subjects desire and seek out physical pain in order to feel something, to know they are alive:

I often feel dead inside and out… like there is nothing inside my body – no feelings or emotions. I am just an empty shell. When I feel like this there is a huge numbness that takes over my whole body. I can’t feel anything and often will cut to try and get some feeling or emotion or just to try and feel the physical pain. (Sutton, 2007, pp. 216–217, my emphasis)

Indeed SIB enables the individual to return to reality:

Sometimes before I self-injure I feel dissociated. The world looks like a dio- rama or a movie set. Objects, environment and people seem two dimensional, like cardboard cut outs on a stage. Sometimes I barely even recognize what things are. Objects appear to be randomly placed about a room. Light becomes over bright or dims. My sense of touch is disturbed, sensations echo which is confusing. For example, I can be lying in bed and every part of my body that is touching something else, pyjamas, sheets, pillow, bed, etc., is tingling and echoing – I’m not sure what I’m touching because I can’t feel the outlines of whatever it is. I fnd that I can’t do up the buttons on my clothing, unless I look directly at them. I’ve noticed this happens when I am under stress, particularly if I feel guilty about something. Sometimes I see the world from over my shoulder, or slightly above myself. I watch myself doing things like typing without being aware that I am directing my body to do so. I have also had that sensation while self-injuring. I watch myself in an internal stupor as my body tears itself up, engages in bizarre rituals (like bottling 6 SELF-INJURING BEHAVIOR 119

or displaying blood and fesh) without me really knowing why. This is the emotional state I am in when I self-injure to “get back to reality”, to rem- edy dissociation. (pp. 218–219, my emphasis)

Yet in other cases SIB facilitates detachment. In these instances, subjects injure themselves without feeling any pain, and the very act of self-injury enables them to become detached and thus dispose of the emotional pain:

I go into a “trance” where I can watch what is going on, I see what is happening, I experience the cutting and the bleeding, but I feel no pain and I cannot stop the actions. No matter the severity of the cutting, I feel no pain. Hours later, at the site of the injury, I feel no pain. It is as if it never happened – great gaping wounds yet no pain – going into shock from loss of blood, yet no pain. No physical pain from the injury and no emotional or mental pain because I have temporarily released it all by cutting. (p. 220, my emphasis)

Stephanie is a perfect example of a subject who uses SIB as a dissociation strategy:

I try to achieve that same familiar feeling of numbness but it won’t work. It’s like I can’t turn the switch off any more, and a voice in my head inter- venes: ‘You shouldn’t do it’. When my breathing slows down alarm bells start ringing! I start getting angry with myself then, and feel a strong need to switch off from what’s going on in my head. Cutting myself takes me to that familiar and safe place where I feel a sense of nothingness. (p. 227, my emphasis)

Thus, we suggest that while SIB is “a coping mechanism to manage excruciating emotional states, it can also serve to alter feelings of profound numbness or deadness” (Sutton, 2007, p. 221). Indeed, SIB “seems to be an effective tool for managing dissociation in both direc- tions—to facilitate it when emotions are overwhelming, as well as to diminish it when one feels too disconnected from oneself and the world” (Mazelis, 1998, p. 2). Chapter 5 defned the dissociative mechanism in terms of the ratio between sense of agency (SA) and sense of body-ownership (SBO). Given the unique linkage between SIB and dissociation, we now examine the connection between SIB, SA, and SBO in more depth. 120 Y. ATARIA

Subjects who employ SIB to generate dissociation cannot tolerate the feeling of their body from within (1PP); cannot stand even the slightest sense of ownership toward the body; and can no longer bear to experience the body as lived-body or body-as-subject due to impairments at the body-schema level. In such cases, SIB weakens the SBO. Consequently, the body of the self-harmer becomes more object-like: a body that is no longer one’s own. In contrast, subjects using SIB to decrease their level of dissociation are seeking to recover the lived-body because they are absorbed in-the-world at the body-schema level precisely through this lived-body. In these cases, SIB is a tool via which subjects can strengthen their SBO. SIB enables individuals either to weaken or reinforce the SBO. Yet in other cases, the motivation for SIB is apparently somewhat different. Individuals engage in SIB to send a clear message both to themselves as victim and the perpetrator who controls their body. Indeed, SIB appears to function at both levels—SBO and SA:

Tonight I’ve done everything to distract myself from thoughts of cutting… I feel angry and I’m not very good at that feeling. They say that behind anger is always fear. So I ask myself: “What are you afraid of?” Well, what do you think?! I’m afraid my father will jump right through my skin and scare the silence right out of me. When I put down this pen, who’ll get me frst? My daddy or me? I’d rather get there frst. This belongs to me! cut, cut, cut. (Kim, 1993, pp. 3–4, my emphasis)

Kim’s description reveals that she is trying to regain a sense of control over her body. Clearly, then, SIB is strongly connected to SA. Cutting the body controls the pain and at least seemingly controls its causes and consequences. For the self-harmer, a world in which she injures herself is at least an organized, albeit twisted, one, wherein which she no longer feels helpless. We therefore contend that SIB provides relief not merely through alterations at the body-ownership level, but also because by cutting, the individual gains at least a limited sense of control over her body and feelings (Fig. 6.1).5

5 Clearly, this is not true in all cases: “I see what is happening, I experience the cutting and the bleeding, but I feel no pain and I cannot stop the actions” (Sutton, 2007, p. 220). 6 SELF-INJURING BEHAVIOR 121

•overwhelmed by •feels the pain feelings •does not feel •increases •dissociated feelings •no feelings at all SIB the pain (2/3), Dissociaon Relief •decreases •back to ground (e.g., depersonalizaon) scores high on the DES

Fig. 6.1 Trade-off between dissociation and self-injuring behavior (SIB can follow two different pathways: For some, SIB is a method that promotes dissociation, while for others it is a tool to diminish the dissociative state)

6.7 the Phenomenology of SIB As was discussed in Chapter 2, when we touch our right hand with our left hand, we can distinguish between the hand that is touching and the hand being touched. Yet both hands are part of one whole that is able to touch itself and can thus act simultaneously as subject and object (Husserl, 1989; Merleau-Ponty, 2002). This basic structure of touching/ being-touched is the result of our unique twofold nature as humans and maintaining both the subjective and objective dimensions is a prerequisite for being a human being (Merleau-Ponty, 1968). This twofold structure collapses during severe trauma. SIB is one of the possible outcomes of this collapse. Indeed, as many testimonies have shown, subjects engaging in SIB do not feel the body from within and do not treat the body as the lived-body. Instead, they treat their body as a pure object and from a third-person perspective. This inability to be simultaneously subject and object indicates a discrepancy between body-schema and body-image. In turn, such a mismatch can result in a sense of disownership. This subsection examines SIB in the context of body-schema and body-image.

6.7.1 SIB at the Body-Schema Level: Being-in-a-Hostile-World In cases of severe and ongoing trauma, the body itself keeps the score, storing the traumatic memory deep within it. Yet it is not the body-as-object but rather the body-as-subject that keeps score. Bodily existence within the world is deeply seated within the trauma, to the point that being-in-the-world is transformed into being-in-a-traumatic- world. The body and the world can neither be separated nor examined independently. Hence, both become completely occupied with the trauma: As we have seen, in these cases the very structure of the body-schema is occupied with pain and unbearable suffering. 122 Y. ATARIA

Furthermore, in severe traumatic cases, the victim embraces the victimizer’s ideology at the body-image level to the extent that the victim’s own sensorimotor loops become saturated with self-hatred. As a result, the victim’s very existence can be defned as being-in-hostile-world, making being-in-the-world painful, or even impossible. Indeed, the addicted self-harmer is unable to perceive the world without these deeply rooted feelings of self-hatred precisely because as humans we must be-in-the- world through our living-body, “which is never absent from the perceptual feld” (Husserl, 1936/1970, p. 106). Hence, if the body-as-subject becomes loaded with feelings of self-hatred, the perceptual feld turns against the self-hating individual, making the world unbearable because “in my perceptual feld I fnd myself” (p. 108). Clearly, nothing is more diffcult for self-harmers than being within their own body. Indeed, from self-harmer’s point of view, nothing is harsher than relying on one’s body-schema when engaging with the world. We thus propose that self-harmers use SIB in an attempt to terminate the body-schema and exist purely at the level of body-image. SIB allows self-harmers to shift from being-in-the-world to being-outside-the-world, or from existence at the level of the body-as-subject to existence at the level of body-as-object. Such a shift obviously increases the dissociative experience. Likewise, during this shift from body-schema to body-image, victims embrace the perspective of the Other who hates them, resulting in a strong sense of alienation, as described in the next section.

6.7.2 SIB at Body-Image Level: The Body-for-Itself-for-Others As we saw, when self-harmers are absorbed within the world at the body-schema level, they embrace SIB to shift their existence to the body-image level. In contrast, when self-harmers embrace SIB while absorbed at the body-image level, they do so because they have embraced a third-person perspective of themselves. They have accepted the perpetrator’s ideology and treat their body as the perpetrator treated it—a pure object to be annihilated. Sartre’s philosophy may improve our understanding of this notion. Sartre proposes three ontological dimensions: In the frst dimension, “I exist my body” (1956, p. 351), while in the second dimension, “my body is utilized and known by the Other” (ibid). The third dimension differs fundamentally, “I exist for myself as a body known by the Other” 6 SELF-INJURING BEHAVIOR 123

(ibid). Dillon (1998) defnes this ontological dimension as the body-for- itself-for-others. In Sartre’s words, “with the appearance of the Other’s look I experience the revelation of my being-as-object” (1956, p. 351). According to Sartre, then, “it is by means of the Other’s concepts that I know my body” (p. 355). Sartre’s concept of the body-for-itself-for-others is rooted in the notion that “either it [the body] is a thing among other things, or else it is that by which things are revealed to me. But it cannot be both at the same time” (p. 304). Thus, if the body is not a lived-body, it must become a pure object:

For my hand reveals to me the resistance of objects, their hardness or soft- ness, but not itself. Thus I see my hand only in the way that I see this inkwell… there is no essential difference between the visual perception which I have of the doctor’s body and that which I have of my own leg. (Sartre, 1956, p. 304, my emphasis)

Sartre and Merleau-Ponty clearly disagree on this point. While Merleau- Ponty’s philosophy is rooted in the body-schema, Sartre’s philosophy is founded upon the body-image and is situated in a dichromic and polarized world. The self-harmer is familiar with this polarized world, which in effect is a posttraumatic world. At the level of body-image, SIB is deeply embedded in negative core beliefs concerning the self. These beliefs can lead not only to low self- esteem but also to feelings of self-dislike and self-loathing. As Yates (2009) proposes, childhood abuse can cause children to internalize blame for the abuse and generate a strong belief that they are bad and unworthy; consequently “what was once external to the child becomes internalized and operational in actively shaping subsequent development” (p. 124). Indeed, researchers claim that a sense of hostility is strongly associated with guilt, self-criticism, self-dislike, and SIB (Ross & Heath, 2003). In particular, studies demonstrate that among women self-blame has the strongest effect on the relationship between childhood mistreatment and SIB (Swannell et al., 2012). Others further maintain that SIB is “prompted by anger at oneself” (Brown et al., 2002, p. 201). This technique of turning anger inward results from a process in which victims learn from their environments to punish, disregard, or otherwise invalidate themselves in extreme ways (Linehan, 1993). Considering this, let us examine the following example: 124 Y. ATARIA

I don’t want this part of me. I won’t look at it – I won’t touch it except to clean it – if I ignore it maybe it will go away. If I hate it then it won’t hurt me – if I feed it, it will stay ugly and nobody else will want to touch it. This part of me makes me feel like shit. I don’t want it to be part of me, so I don’t listen to it – I want it to go away and never come back – it isn’t mine and I don’t want it – if I never saw it again I wouldn’t care. If I look at it it makes me feel sick – I hate it – I won’t take care of it. Why should I? It’s let me down in the past and I don’t trust it. If I could, I’d tell it to ‘Fuck off’ – if I could I’d throw it in the waste disposal. If I’m honest with myself I would say I’m angry with it. It’s the reason I feel so bad – it’s a waste of space and it’s so ugly – Yukk!!! (Sutton, 2007, p. 149, my emphasis)

It seems that Sartre has revealed the phenomenology of the self-harming individual. At the body-image level, the self-harmer exists as being-for- others: “being-a-tool-among-tools” (Sartre, 1956, p. 352). Clearly, the self-harmer’s “body is designated as alienated” (p. 353). Indeed, Sartre perfectly describes the self-harming individual’s state of mind while experiencing being-in-the-world at the body-image level. Yet as we saw, SIB can function on both levels: body-schema and body-image.

6.7.3 SIB: Body-Image Versus Body-Schema A sense of disgust and hatred toward one’s body can develop either at the body-image level or the body-schema level. Although a sense of disgust for one’s body at the body-image level has dramatic consequences, one’s basic ability to be in-the-world with and through one’s body remains at least somewhat undamaged. More specifcally, under such circumstances, individuals can loathe their body and even totally adopt the victimizer’s perspective and ideology. Nonetheless, on the pre- refective 1PP level, they retain the ability to be present in-the-world from within the body. This 1PP/3PP detachment is expressed through a growing tension between the body-schema and the body-image which, in turn, can lead to a confict between the body-as-subject and the body-as-object. Assuming that SIB is a mechanism which facilitates regulation, when victims develop SIB due to impairments at the body-image level, they are attempting to break out of a state of dissociation. Individuals are present in-the-world at the body-image level from a 3PP. Hence, in addition to the fact that SIB symbolizes adoption of the victimizer’s perspective, the 6 SELF-INJURING BEHAVIOR 125 act serves as an attempt to separate oneself from an existence wherein the body is treated as-an-object and the world is experienced from the 3PP. In turn, SIB at the body-image level can lead to existence at the body-schema level, where the individual can experience the body from the 1PP as a living-body in-the-world. When the body is attacked under such circumstances, the body-as-object that is attacked, not the world itself. Total repression of an event, for example by coding it solely on the bodily and sensorimotor level and not subjecting it to any higher cognitive coding, may cause signifcant damage at the body-schema level but not necessarily at the body-image level. The case of encoding the trauma at the body-schema level can cause signifcant damage to the SBO. In practice, the victim becomes incapable of experiencing the body as a lived-body from a 1PP because the very existence at the body- as-subject level is nothing less than torture. When the individual experiences the world through the body, the world becomes fooded with suffering and pain. Under such circumstances, the SBO is unbearable even at the lowest level. No longer capable of experiencing the body from the inside (1PP), victims may develop a SIB strategy that will enable them to experience the world from a 3PP at the body-as-object or body-image level. When the self-harmer engages in SIB at the body-image level but not at the body-schema level, the purpose of self-harm is to regain some sense of ownership toward the body. In contrast, the purpose of engaging in SIB at the body-schema level but not at the body-image level is to stop feeling the body-as-subject because the victim is incapable of coping with SBO at the lowest level. Indeed, even the weakest sense of ownership toward the body leads to self-harm. Thus, by engaging in SIB, self-harmers attempt to escape the torture of feeling the body from the inside. As we have seen, at the body-schema level, the boundary between body and world is not sharp and clear; thus, the body-as-subject enables us to be present and absorbed in-the-world and feel at-home. Self- harmers who cause damage at the body-schema level are not harming the body-as-an-object from the outside. Rather, they simply cannot tolerate their primal presence in-the-world because the world itself is unbearable and their presence in-the-world in this body is unbearable as well. Thus, they injure themselves in an attempt to detach their self and reduce their SBO. 126 Y. ATARIA

Self-injury at the body-schema level rather than the body-image level can also be described in terms of structural dissociation. The attack on the body is an attack on traumatic memories burned deeply into the body. Indeed, in such situations, denial of the SBO is equivalent to the denial of traumatic memories and vice versa—denial of the traumatic memories is manifested in a denial of the SBO. Hence, in attacking the body, the individual is not adopting the victimizer’s perspective but rather expressing the impossibility of being present in the body because that very presence is torture. The phenomenology of SIB reveals major defects in the most basic body-schema mechanisms which enable us to be-in-the-world. We saw that SIB is often related to severe and ongoing trauma, especially during childhood (but not only). Indeed, one of the results of severe and ongoing trauma appears to be complex posttraumatic stress disorder (C-PTSD). In the next chapter, we will show that severe and ongoing trauma, body-disownership, SIB, and C-PTSD are closely linked.

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The Destructive Nature of Complex PTSD

7.1 the Complex Nature of PTSD In 1980, after the psychiatric system had long denied the existence of posttraumatic stress disorder (PTSD), the American Psychiatric Association (APA) added PTSD to the third edition of its Diagnostic and statistical manual of mental disorders (DSM-III) (American Psychiatric Association, 1980). People suffering from PTSD may relive the traumatic event via intrusive memories, fashbacks, and nightmares; avoid anything that reminds them of the trauma; and experience the onset of intense anxiety which disrupts their lives. While DSM-III (American Psychiatric Association, 1980) determined that it was necessary for an individual to undergo a traumatic event in order develop PTSD, over the last thirty years thinking has changed. According to the DSM-5 (American Psychiatric Association, 2013), wit- nessing or even merely hearing about the death or injury of a relative can be suffcient for PTSD to ensue. Diagnostic criteria for PTSD (American Psychiatric Association, 2013) include exposure to a traumatic event that meets specifc stipulations and the presentation of symptoms from each of four symptom clusters:

1. Re-experiencing, such as fashbacks. 2. Avoidance of memories, thoughts, feelings, or external reminders of the event.

3. Negative cognitions and mood—for instance, a persistent and distorted sense of blame of self or others, estrangement from others or markedly diminished interest in activities, an inability to remember key aspects of the event. 4. Arousal marked by aggressive, reckless or self-destructive behavior, sleep disturbances, hypervigilance and the like.

In contrast to its predecessors, DSM-5 defnes a dissociative subtype of PTSD. This modifcation is a result of various studies conducted over the last 30 years that reveal a strong link between PTSD and dissociation (Birmes et al., 2003; Breh & Seidler, 2007; Bremner et al., 1992; Briere, Scott, & Weathers, 2005; Candel & Merckelbach, 2004; DePrince, Chu, & Visvanathan, 2006; Gershuny, Cloitre, & Otto, 2003; Marmar, Weiss, & Metzler, 1998; Marmar et al., 1994; Marshall & Schell, 2002; Murray, Ehlers, & Mayou, 2002; Ursano et al., 1999; Van der Velden & Wittmann, 2008). Indeed, it is well documented that dissociation levels are signifcantly higher in cases of survivors with PTSD, particularly chronic and complex PTSD (C-PTSD), and that the probability of developing severe PTSD symptoms is associated with a high level of dissociation. That is, the intensity of the dissociative symptoms correlates positively with the intensity of the PTSD symptoms (Carlson, Dalenberg, & McDade-Montez, 2012; Ginzburg, Butler, Saltzman, & Koopman, 2010). Thus, based on a wide review of the relevant literature, Lanius et al. (2010) argue that we can frmly distinguish a dissociative subtype of PTSD from non-dissociative PTSD, not only clini- cally but also on the neurobiological level. According to the DSM-5, the dissociative subtype of PTSD is principally characterized by symptoms of depersonalization—the experience of being an outside observer or being detached from oneself, as if “this is not happening to me” or as though one is in a dream—and derealization—the experience of unreality, distance, or distortion (e.g., “things are not real”). Studies (Stovall-McClough & Cloitre, 2006; Van der Kolk, Pelcovitz, Roth, & Mandel, 1996; Waelde, Silvern, & Fairbank, 2005) strongly support the existence of such a dissociative subtype of PTSD. For instance, one study found that among a sample of war veterans exposed to trauma Wolf et al. (2012), 6% suffer from severe PTSD accompanied by pathological dissociative symptoms—e.g., derealization and depersonalization. Furthermore, relative to trauma survivors who exhibit low levels of 7 THE DESTRUCTIVE NATURE OF COMPLEX PTSD 133 dissociation, those suffering from PTSD accompanied by high levels of dissociation tend to score higher on PTSD severity tests (Hagenaars, Van Minnen, & Hoogduin, 2010).1 Based on a review of the scientifc literature, we suggest that (a) chronic PTSD goes hand in hand with chronic symptoms of dissociation and (b) a dissociative subtype of PTSD usually occurs following prolonged traumatic experiences, such as chronic childhood abuse or trauma during severe and prolonged combat. In more general terms, a dissociative subtype of PTSD usually follows what Terr (1991) defnes as trauma type II: “PTSD patients with prolonged traumatic experiences such as chronic childhood abuse or combat trauma often show a clinical syndrome that is characterized by chronic symptoms of dissociation” (Lanius et al., 2010, p. 641). This notion can be further generalized: “Subjects with both PTSD and disorders of extreme stress not otherwise specifed exhibited chronic symptoms of dissociation as evidenced by higher scores on the Dissociative Experiences Scale than participants who were suffering from PTSD only” (p. 644). Thus, a dissociative subtype of PTSD is linked, at least in some cases, with (a) prolonged and severe trauma and (b) C-PTSD (Carlson et al., 2012; Ginzburg et al., 2010). C-PTSD, also referred to as disorders of extreme stress not otherwise specifed (DESNOS), includes the core symptoms of PTSD (re-experiencing, avoidance/numbing, and hyperarousal). According to Herman (1992a, b), however, classic PTSD fails to explain the various symptoms that some posttraumatic survivors (e.g., trauma type II) develop.2 These symptoms include (a) emotion regulation diffculties; (b) disturbances in relational capacities; (c) dissociation; (d) adverse effects on belief systems; and (e) somatic distress or disorganization. C-PTSD usually results from exposure to repeated or prolonged trauma, such as incarceration in prisons, concentration camps or slave labor camps, and incest (i.e., trauma type II). Unsurprisingly, a recent study (Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013) reveals that although an individual’s history does not determine the diagnosis (Courtois, 2004), childhood abuse can predict C-PTSD, at least to some degree.

1 It is unsurprising and also critical that this high dissociation subgroup responded less successfully to PTSD treatment. 2 For critical reviews see Resick et al. (2012). 134 Y. ATARIA

Not only is the symptomatology of those with C-PTSD apparently more complex than that of those with simple PTSD (see above). Rather, some victims of ongoing trauma develop characteristic personality changes, including identity distortions. Furthermore, in severe cases survivors are highly vulnerable to repeated harm, not merely by others but literally at their own hands (as was discussed in the previous chapter).

7.2 c-PTSD from a Phenomenological Perspective Ordinarily, “[w]hen one feels ‘at-home’ in-the-world, ‘absorbed’ in it or ‘at one with life’, the body often drifts into the background” (Ratcliffe, 2008, p. 113). Yet when no longer able to feel at-home within the world, the body as a whole becomes increasingly salient as an object. Accordingly, as the sense of belonging decreases, one experiences the entire body less as a lived-body and more as an object. In such a situation, “the body is no longer a medium of experience and activity, an opening onto a signifcant world flled with potential activities.” Instead, “it is thing-like, conspicuous, an object… an entity to be acted upon” (p. 113). Indeed, feeling that the body is more salient, or indeed less absent, clearly indicates the existence of a problem. During experiences of pain and suffering, the body becomes thing- like. Suffering can be defned as a mood (Heidegger, 1996) or as existential feelings (Ratcliffe, 2008). When we are ill or depressed, we may begin to feel that everything is beyond our capabilities. The tools in our surroundings become inaccessible; the world refuses to be manipulated and ceases to be a bodily world. This sense of inaccessibility refects bodily dysfunctions, because when the body functions properly, it is (almost) totally forgotten. In contrast, however, “at times of illness one may experience one’s body as more or less ‘unuseable.’ It no longer can do what once it could… fnally, the sick body may be experienced as that which ‘stands in the way,’ an obstinate force interfering with our project” (Leder, 1990, p. 84). Thus, “at times of dys-appearance, the body is often (though not always) experienced as away, apart, from the self. Surfacing in phenomena of illness, dysfunction, or threatened death, the body may emerge as an alien thing, a painful prison or tomb in which one is trapped” (p. 87). Indeed, during suffering, the body becomes an obstacle. A melancholic individual, for example, “collapses into the spatial boundaries of her own solid, material body,” and consequently, “instead 7 THE DESTRUCTIVE NATURE OF COMPLEX PTSD 135 of transcending the body, she becomes completely identifed with it” (Fuchs, 2005, p. 100). Thus, the melancholic individual becomes totally identifed with the corporealized body. Precisely at these moments, the equilibrium between the lived-subjective body and the dead-objective body tips toward the body-as-object. When the body is in pain, we are in-the-world through this pain (Scarry, 1987). The phenomenology of pain reveals that a body in pain becomes less a lived-body, less transparent, and more salient: We begin to experience it as an obstacle. Individuals who are in pain wish their body would once again become an implicit part of their experience. Yet instead, the body becomes the focus of attention, an explicit part of the experience. Furthermore, pain shapes the structure of the phenomenological feld, reducing space and time to the bodily dimension (Leder, 1990; Ratcliffe, 2015). The I-can horizon shrinks and the sense of belonging to the world undergoes radical modifcations. In addition, pain wreaks immediate destruction in the social sphere. When we are in pain, we feel that others do not fully understand us. Likewise, we fnd it impossible to describe our experience. In addition to feeling somewhat isolated from others, we also begin to feel disconnected from ourselves and even “foreign to the self” (Leder, 1990, p. 76). This experience is the result of a process by which the body becomes the intentional object of perception, leaving us to exist at the body-image level only. Our body ordinarily allows us to be part of the world, but when we are in pain the very structure of our body changes. Leder (1990) suggests that the most signifcant outcome of illness is alienation from the world because, in this new state of affairs, the intentional structure is now directed toward the body. The I-can phenomenological feld is transformed into an I-can-not kind of feld because the body does not allow us to act. Fuchs (2005) defnes this process as corporealization: “The body does not give access to the world, but stands in the way as an obstacle, separated from its surroundings: The phenomenal space is not embodied anymore” (p. 99). In this situation, the world is beyond our reach. Thus, not only does the phenomenal feld become an I-can-not kind of feld, but we begin to feel disabled, restricted, and immobilized, as though external forces prevent us from acting in-the-world. The process described here indicates that this sense of non-belonging is rooted in some defcits at the body-schema level. Let us elaborate on this notion further. 136 Y. ATARIA

In the process of corporealization, the knowing-how structure— our ability to master a skillful activity and perform it in our daily life (Noë, 2004; O’Regan & Noë, 2001a, 2001b)—is damaged. Thus, the knowing-how structure may even become inaccessible, leading to a sense of helplessness (Arieli & Ataria, in press). As noted in the Introduction, in cases of prolonged and ongoing trauma the victim’s sensorimotor loops undergo radical changes. Hence, to continue functioning, the victim must update these sensorimotor loops by constructing a new system which connects between expectations and actual possible outcomes, thus modifying the knowing-how structure. In the long term, however, such outcomes can be devastating because the very structure of the sensorimotor loops has now become embedded within the trauma. As a result, the individual cannot avoid the trauma while approaching the world in an enactive manner. Thus, the individual perceives the world through the trauma, not only during the traumatic event but even after it has ended. Hence, to say that the body keeps score is to say that the structure of the sensorimotor loops has become embedded within the trauma and is unable to fnd release from that moment. In practice, this means that the traumatized individual’s practical beliefs and expectations have adjusted to the world of trauma. Given that the sensorimotor loops constitutes the structure of our 1PP, embracing a 1PP following severe and ongoing trauma, will immediately project the posttraumatic survivor into the moment of trauma. Thus, the individual must renounce the 1PP, avoiding the lived-body in order to continue functioning in-the-world, and shift from 1PP to 3PP. Indeed, when the sensorimotor loops are flled with trauma, the only alternative is to embrace a 3PP toward the body. Under such circumstances, the equilibrium between body-as-subject and body-as-object collapses; the body becomes a pure object. This mechanism forms the underlying foundation for the long-term outcomes of severe and ongoing trauma. Phenomenologically, for those suffering from C-PTSD, the body becomes an IT. We can no longer exist on the level ofthe living-body or the body-schema; the world is no longer accessible. Instead, the survivor exists at the level of the body-as-object or body-image. Ultimately, an unbridgeable gap emerges between body-schema/image and body- as-subject/object; these two become enemies. The remainder of this 7 THE DESTRUCTIVE NATURE OF COMPLEX PTSD 137 chapter seeks to pinpoint this notion, frst by analyzing the concept of structural dissociation.

7.3 structural Dissociation Under conditions of dissociation, events that are usually linked become disconnected, detached, and distinct. Conscious parts of the “self” become separated and acquire a sense of independence, “selfness” and separateness. Moreover, dissociative states are often marked by emotional numbness or apathy. In more severe cases, individuals may feel as though they are controlled by outside forces and lack the ability to resist them. Over the long term, the dissociative mechanism during trauma can develop into complex dissociative clusters such as multiple personality disorder; these “are almost always associated with a childhood history of massive and prolonged abuse” (Herman, 1992a, p. 381). In some cases, dissociation during trauma can develop into structural dissociation. In this situation, the survivor has (at least) two different and contradictory personalities, each unaware of the other: the “apparently normal” and the “emotional” parts of the personality (Nijenhuis, Van der Hart, & Steele, 2010; Van der Hart, Nijenhuis, Steele, & Brown, 2004).3 Under such circumstances, survivors may feel totally disconnected from the traumatic event, to the point of not even remembering it. Conversely, they may experience the trauma anew in the here and now, usually due to environmental stimuli of which they are totally unaware of. The contradictory relationship between avoidance and re-experience is intrinsic to structural dissociation. This is the relationship between the apparently normal personality (ANP), obsessed with keeping the traumatic memories at bay, and the emotional personality (EP) fxed within the traumatic experience (Myers, 1940). Nijenhuis et al. (2010), concurring with Reinders et al. (2003), contend that it is possible for different senses of self to represent these two personalities or two dissociative parts of the

3 This notion can be defned as dissociative parts of the personalities. I would like to thank Onno Van der Hart for this important comment. 138 Y. ATARIA personalities (ANP and EP). Whereas the ANP is characterized by loss of memory, sensory, and perceptual or motor functions, the EP is a physical dissociation involving sensorimotor traumatic re-experiences and fashbacks. EP is related to somatoform dissociation. Indeed, according to Myers (1940), one package of symptoms (ANP) results from the obses- sive attempt to avoid the traumatic memory—amnesia, depersonalization, anesthesia, analgesia, and paralysis. The other package (EP) reactivates the trauma on the sensorimotor level, as though two different personalities exist within the same person. This EP/ANP confict can be refor- mulated as a struggle between body-as-subject and body-as-object or between body-schema and body-image: EP/ANP body-as-subject/ = object body-schema/image. = As time passes, the separation and confict between the EP and the ANP intensify. During any new fashback, new bodily and context- independent stimuli become connected to the EP, yet the stimuli that reactivate the EP remain hidden, silent, and unknown at the body- schema level. Thus, to function normally, the ANP seeks to avoid increasing numbers of stimuli: its feld of avoidance constantly grows. At the end of this process, the world itself is being avoided. The relationship between the EP and the ANP can be defned as an internal confict between two forces. The posttraumatic survivor attempts to dispose of the EP, which has been burned deeply into the body. Indeed, from the ANP’s perspective, disposal of the EP is vital for survival; if not destroyed, the EP will eventually terminate the ANP and take control of the entire personality. In view of this, we suggest defning structural dissociation in terms of two opposing personalities striving for mutual destruction. A classic example of such an inner confict between the ANP and the EP occurs between Mike (Michael Vronsky, played by Robert De Niro) and Nick (Nikanor Chevotarevich, played by Christopher Walken) in the movie The Deer Hunter (Cimino, 1978). After playing Russian roulette in a Vietcong prison, Mike returns home, only to discover that his very concept of home has collapsed. Nick, by contrast, remains in Vietnam obsessively playing Russian roulette. Mike and Nick are essentially the same person living in two parallel time dimensions: Mike represents the ANP, apparently living the present moment, while Nick represents the EP, which remains frozen in the moment of trauma. At the end of the movie, Mike returns to Vietnam, ostensibly in order to save Nick. Yet on a much deeper level, Mike (ANP) knows that to survive, he must eliminate his traumatic memory by murdering Nick (EP). Indeed, the 7 THE DESTRUCTIVE NATURE OF COMPLEX PTSD 139 solution always lies in the termination of one of the characters— the ANP or the EP. For that reason, the director of The Deer Hunter leaves the viewer with the impression that Mike (ANP) shoots Nick rather than that Nick kills himself. Nevertheless, they are the same person, and therefore, it does not really matter whether Nick shoots himself or Michael shoots Nick. This duality represents the condition of the posttraumatic survivor, constantly embroiled in an impossible confict between the ANP and the EP. The same is true of Captain Benjamin L. Willard (played by Martin Sheen) and Colonel Walter E. Kurtz (played by Marlon Brando) in the movie Apocalypse Now (Coppola, Conrad, & Coppola, 1979). They too both represent the same character: Willard is the ANP, and Kurtz is the EP. Willard must annihilate Kurtz in order to survive; otherwise, the EP (Kurtz) will take over the ANP. Indeed, in the fnal scene of the movie, Willard kills Kurtz. These examples, which have been examined at length elsewhere (Ataria, 2017), are not based on clinical studies yet offer us some insight into the experience of the posttraumatic survivor suffering from structural dissociation; the latter, in turn, can lead to disownership toward the entire body—a brutal mechanism causing one to identify oneself as the enemy. To understand this mechanism, we must return to the bodily structure of traumatic memory. As we saw, the traumatic memory is burned onto the body so deeply that the body can never forget it (Scaer, 2007). Thus, trauma does not undergo high-level processing, nor does it become a symbol, but rather remains sensory and somatic. Consequently, the trauma cannot be transformed into an explicit memory but rather remains implicit, in the form of a bodily memory at the body-schema level (Van der Kolk, 1994; Van der Kolk & Fisler, 1995). This bodily memory of trauma is the quin- tessence of the EP, which in turn represents the body, still frozen in the moment of trauma. Thus, in simple terms the EP is reduced to the actual traumatic bodily memories themselves; as such, it is the source of pain and suffering, serving as a constant threat to the ANP, which tries to avoid or eliminate it. In order to eliminate traumatic memories, victims may harm or even destroy their own bodies as the source of pain and suffering. This EP/ANP confict is characterized by uncontrollable rage that cannot be directed at the outside world and instead turns inward (e.g., SIB). We now examine this deadly combination of self-injuring behavior (SIB), structural dissociation, and C-PTSD, beginning with SIB and PTSD. 140 Y. ATARIA

Scholars have discerned a signifcant correlation between SIB and heightened PTSD symptoms (Weaver, Chard, Mechanic, & Etzel, 2004). Some have even argued that “after a full history was obtained, it became clear that the self-cutting was part of a posttraumatic stress disorder” (Greenspan & Samuel, 1989, p. 789, my emphasis). In particular, re-experiencing in combination with avoidance/numbing symptoms appears to mediate between trauma and SIB (Weierich & Nock, 2008). As noted, the re-experiencing/avoidance confict constitutes the very core of structural dissociation (ANP versus EP). Yet we suggest that structural dissociation and SIB are rooted in—and emerge from—the same re-experiencing/avoidance confict. An important feature of severe and ongoing trauma such as traumatic abuse or captivity is the victim’s inability to express anger toward the perpetrator. Indeed, long after the abuse has ended or the prisoner has been released, this inability to express anger toward the perpetrator remains a fundamental problem: “Even after release, the survivor may continue to fear retribution for any expression of anger against the captor” (Herman 1992a, p. 382). If survivors cannot fnd a non-harmful way to channel their anger toward an external source, they may begin to direct this anger inwardly. The deadly combination of uncontrollable rage and a sense that the body is the source of pain can generate the feeling that one’s own body is the enemy. Accordingly, to provide relief, even momentary in nature, the posttraumatic survivor may try to destroy the body. Some studies have even found that anger and hostility appear to be strongly associated with PTSD and, no less important, that non-manageable anger is a mediator between PTSD and SIB (Orth & Wieland, 2006). In particular, studies reveal (Franklin, Posternak, & Zimmerman, 2002) that a group of subjects classifed as suffering from C-PTSD (e.g., PTSD with comorbid borderline personality disorder) exhibited higher levels of anger than individuals with less complex PTSD. Likewise, a study of 46 clients attending an urban community therapy service in Belfast (Dyer et al., 2009) revealed signifcant differences in physical aggression levels between the C-PTSD group and the PTSD group: While 58% of the PTSD group had a history of self-harm, 91% of participants in the C-PTSD group engaged in SIB. Specifcally, this study indicates that “the C-PTSD group have shown much greater physical aggression at this level than the PTSD group” (Dyer et al., 2009, 7 THE DESTRUCTIVE NATURE OF COMPLEX PTSD 141 p. 1105). These fndings are thus critical to our understanding of the cognitive mechanisms activated during C-PTCD. A meta-analysis (Orth & Wieland, 2006) reveals a low correlation between anger-out, that is, rage and aggression which are directed out- ward and not inward, and PTSD. In view of this low correlation, together with the proposal of the meta-analysis study that “strong posttraumatic stress reactions reduce the ability of an individual to control anger by decreasing mental resources” (Orth & Wieland, 2006, p. 703), we contend that at least in some cases, the victim’s anger is directed inward. Thus, we maintain that as posttraumatic symptoms become harsher: (a) the confict between the ANP and the EP intensifes, (b) the sense of rage increases, (c) the ability to control anger decreases, and (d) the tendency to direct rage inward escalates: SIB thus becomes unavoidable. This becomes even more evident when we understand that an important feature of trauma type II is the victim’s tendency to identify with the perpetrator. During severe and ongoing trauma, victims may undergo a process of internalization at the body-image level. Not only do they accept that they are getting what they deserve, they also internalize the notion that they are unworthy and even responsible for what is happening to them. In severe and ongoing trauma, the perpetrator has full and total control over the victim. This control goes beyond the physical reality: In a deeper sense, the perpetrator gains controls over the victim’s mind: “the perpetrator becomes the most powerful person in the life of the victim, and the psychology of victim is shaped over time by the actions and beliefs of the perpetrator” (Herman 1992a, p. 383). This may lead the victim to identify totally with the perpetrator:

As the victim is isolated, she becomes increasingly dependent upon the perpetrator, not only for survival and basic bodily needs, but also for information and even for emotional sustenance. Prolonged confnement in fear of death and in isolation reliably produces a bond of identifcation between captor and victim. This is the “traumatic bonding” that occurs in hostages, who come to view their captors as their saviors and to fear and hate their rescuers. (Herman, 1992a, p. 384)

One plausible result of this traumatic bonding is self-harming or self-injuring behavior. Indeed, “self-injury and other paroxysmal forms of attack on the body have been shown to develop most commonly in those 142 Y. ATARIA victims whose abuse began early in childhood” (Herman, 1992a, p. 387). Based on the above discussion of structural dissociation, we now present a more comprehensive model of body-disownership.

7.4 toward an Understanding of Body-Disownership As noted, severe trauma, dissociation, SIB, and complex posttraumatic symptoms are strongly linked. The damage caused by trauma can be so fundamental that survivors are no longer able to be-in-the-world at the body- schema level; their sense of belonging declines, and they can no longer feel at-home within the world. Likewise, survivors’ SBO diminishes and, at times, disappears altogether. Indeed, in the wake of severe and ongoing trauma, the SBO becomes a bipolar and defective mechanism marked by an SBO that is either too strong or altogether missing. This defect is crucial because the SBO’s fexible ability to become weaker or stronger in accordance to varying conditions enables us to adapt to the world. Despite this loss of the SBO’s fexibility, survivors must nevertheless fnd a way to continue acting and functioning in-the-world. To this end, as in the case of Ian Waterman, survivors rely on body-image and avoid their body-schema, resulting in a mismatch between body-image and body-schema. As we have seen, such a mismatch has far-reaching implications for how individuals experience their own body. In the case of BIID, for instance, damage at the body-schema level can even result in cutting off a disowned limb. Note that the same mechanism that is activated toward the subject’s own limb can incontrovertibly be applied to the whole body as well.4 Disownership is accompanied by a basic sense of hostility toward one’s own body, whether toward one limb or toward the entire body. In this sense, disownership fundamentally differs from a lack of SBO. Indeed, meditative states are characterized by a lack of SBO (Ataria, 2015d; Ataria, Dor-Ziderman, & Berkovich-Ohana, 2015) yet they are deeply relaxing. This is not the case with disownership. By its very nature, this cognitive mechanism is destructive (Fig. 7.1).

4 The same mechanisms responsible for SBO in the case of RHI (see Chapter 3) also operate in the case of the entire body. 7 THE DESTRUCTIVE NATURE OF COMPLEX PTSD 143

Fig. 7.1 The deadly outcomes of trauma type II. There is a strong connection between the nature of the traumatic experience (trauma type II) and its long- term outcomes. Complex PTSD, together with dissociative subtype of PTSD, can develop into structural dissociation and self-injuring behavior. The deadly combination of uncontrollable rage and the sense of the body as the source of pain can generate a feeling that the body is the enemy. Under such conditions, the posttraumatic survivor may try to destroy the body, in this way gaining some kind of relief, even if only momentarily

So long as individuals engage in SIB, we can say they are still attempting to regulate these unbearable feelings. Yet although SIB may be an effective mood-regulating tool in the short term, it becomes inadequate in the long term, among other reasons because it expands and deepens the disparity and lack of synchronization between body-image and body- schema. Eventually, the survivor becomes unable to bear the absolute separation between body-as-subject at the body-schema level and body- as-object at the body-image level. To clarify this notion further, we must keep in mind that whereas the body-as-subject represents the emotional personality (EP), the body-as- object represents the apparently normal personality (ANP). The bodily memory of trauma is stored in the body-as-subject (EP), and this can therefore potentially become the enemy of the body-as-object (ANP). 144 Y. ATARIA

More precisely, the survivor’s body-schema (EP) becomes a threat which the body-image (ANP) seeks to avoid and, in severe cases, even destroy. Trauma survivors who have developed C-PTSD feel a sense of non- belonging. In practice, this means that they exist at the body-image level, while their traumatic memories are located at the body-schema level. These bodily memories threaten the survivor. Hence, to avoid their bodily traumatic memories, survivors must avoid their body-schema, causing an unbearable discrepancy between body-schema and body-image: The body-schema in effect becomes the enemy of the body-image, just as the EP is the enemy of the ANP.

7.5 toward a Cognitive Model of Body-Disownership As we saw, a mismatch between body-schema and body-image can result, among other things, in somatoparaphrenia (loss of SA and denial of that loss at the level of judgment) or BIID (lack of SBO). Such a mismatch, in turn, results in the denial that one owns the body. In both cases, the individual cannot tolerate even the weakest SBO; the individual suffers from over-presence of the body. Essentially, both SIB and C-PTSD can be defned as a sense of the body’s over-presence, that is, an SBO which is too strong. Indeed, the example of illness can illustrate this further. When we contract an illness, such as the fu, we begin to feel that our body is somehow too present. Feelings of this type can be described as a sense of the body’s over-presence. In this situation, the equilibrium between body-as-subject and body-as-object tilts in favor of the body-as-object; as a result, one’s very existence becomes intolerable. Indeed, as was noted, at the body-schema level the body and the world cannot be separated; hence, when one develops a sense of bodily over-presence, the world itself becomes unbearable and over-present. Figure 7.2 provides a model illustrating a state in which the sense of body-ownership is too strong. As Fig. 7.2a shows, under ordinary circumstances the SBO shifts from Point A to Point B to Point C in accordance with the situation and environmental conditions. Due to this fexibility, the mechanism of the SBO enables us to adapt and function in our environment. 7 THE DESTRUCTIVE NATURE OF COMPLEX PTSD 145

(a)

A Too strong sense of body- ownership C p ownershi - Default state (during our daily life)-D Sense of body B

Lack of sense of body- ownership

(b) Se

A+C nse of b ody-ownersh ip Everyday experience Too strong sense of body- ownership D

Lack of sense of body-ownership

Dissociation (Body-as-subject/object)

Fig. 7.2 Sense of body-ownership that is too strong. a: Under ordinary circumstances, the sense of ownership is transparent, fexible and changes frequently. We move fexibly from one state to another: SBO ranges from point A to point B to point C in accordance with the situation and environmental conditions. b: While Figure 3.3 shows only part of the graph (points D–B in b), fgure b depicts the entire picture. Whereas a lack of SBO can emerge in extreme cases (point B in b), another possibility is an SBO which is too strong–as in the case of C-PTSD combined with SIB (points A+C in b). a compared to b: points A and C in a represent the same phenomena, as represented by points A and C in b. In addition, point B in a represents the same phenomenon as point B in b. In effect, the subject in a cannot access point D in b, which represents our everyday experience 146 Y. ATARIA

In the case of a severe impairment at the body-schema level, even the weakest SBO becomes too strong: One is simply unable to experience the body as one’s own. Such a state represents a mechanistic failure of the SBO, manifested in a loss of fexibility: Instead of moving dynami- cally from Point A to Point B to Point C in accordance with changing environmental conditions, the subject is projected directly between two points—Point A to Point B or Point B to Point C. The entire intermediate space has ceased to exist. Under such circumstances, there are only two states: total lack of an SBO or an SBO that is too strong. At Point A (Fig. 7.2a and b), where the SBO is too strong, the subject adopts SIB to reduce the sense of ownership. Yet, as we saw, due to the collapse of the fexible mechanism, this step does not allow the subject to move slowly toward a weaker SBO. Instead, the subject is thrown toward a lack of SBO—Point B—which is also intolerable. Hence, the subject again resorts to SIB in order to feel the body. Yet again the subject cannot move slowly along the curve but rather is thrown to Point C: The SBO becomes too strong and unbearable.

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Severe and ongoing trauma is marked by the collapse of the most basic structure that makes us human—our dual existence as both subject and object. This collapse can lead to the development of a destructive mechanism, defned in this book as body-disownership: One identifes the body as one’s enemy. This mechanism, in turn, constitutes the nucleus of complex posttraumatic symptoms. Ordinarily, an equilibrium of sorts exists between the lived-body and dead-body, yet in extreme cases, this balance is violated. For example, during a trance induced by the use of hallucinatory drugs, the boundaries dissolve, and the individual’s presence in-the-world becomes more diffuse. In such a state, we are present in-the-world through the lived-body and feel more strongly that we belong to the world, or simply, at-home. In contrast, when we fnd ourselves in more diffcult circumstances, such as when we are ill, our feelings of the body-as-object become stronger; we feel more alienated and less at-home. As this subject–object equilibrium begins to shift toward body-as-object, we begin to relate to our body as another object in our environment. In a certain sense, we cease to feel our body from within (1PP) and begin to relate to it from the outside (3PP) at the body-image level. Extreme cases of severe and ongoing trauma are marked by a disruption in the balance between body-as-subject and body-as-object. Under such circumstances, the victim’s SBO weakens. Consequently, victims

© The Editor(s) (if applicable) and The Author(s) 2018 151 Y. Ataria, Body Disownership in Complex Posttraumatic Stress Disorder, https://doi.org/10.1057/978-1-349-95366-0 152 Body-Disownership—Concluding Remarks experience the world indirectly, as though they themselves are not the one experiencing the event. This dissociative mechanism that should protect the victim during trauma; indeed, in many cases—even in the most diffcult situations—it does just that. Yet, in certain circumstances, the very mechanism which should help us during trauma actually causes collapse and harsh results over the long term. This book has attempted to defne the dissociative mechanism in terms of the relations between sense of body-ownership (SBO) and sense of agency (SA). While SA SBO, the dissociative mechanism remains ≈ intact and functioning. However, as the SA:SBO ratio approaches either zero or infnity, the dissociative mechanism ceases to function, resulting in disintegration. The very nature of the dissociative mechanism causes us to relate to our body-as-an-object, and therefore, its long-term results can be devastating. Although relating to the body-as-an-object can serve as a defense mechanism, it exacts a heavy price. When the trauma is ongoing, and particularly when the victim is dependent on the victimizer (as in the case of captivity or incest), being cut off from the body-as- subject and relating to the body-as-object can lead the victim to adopt the victimizer’s perspective. Victims treat themselves just as their victimizer related to them. To rephrase this notion in cognitive terms: At the body-image level victims of trauma type II (sometimes) internalize the notion that they are worthless and warrant contempt, even believing that they are simply getting what they deserve. Note that this at least provides a logical, yet distorted, explanation for the process. If this mechanism becomes fxed, in the long-term the body is treated as something despica- ble, an object that must be destroyed. Concurrent with impairment at the body-image level, another more destructive process occurs. Relating to the body-as-an-object during trauma does not revoke the existence of the body-as-subject. Hence, despite the supposed separation, the body-as-subject continues to be present during the trauma; indeed, it is thus the body-as-subject that enables us to perceive the world by means of sensorimotor laws connecting between movement, expectation, and sensations. As the trauma continues, the victim creates new perceptual circuits at the body-schema level to facilitate survival and continued functioning. In particular, the victim’s expectations change dramatically. In the short-term, this again serves as a defense mechanism of sorts, allowing the victim to function. Yet in the long term, the changes in these circuits and the concomitant Body-Disownership—Concluding Remarks 153 alterations in expectations transform the trauma victim’s presence in-the- world into a state of ongoing suffering. Thus, individuals who claim that the world is unbearable are in effect describing their bodily experience of being-in-the-world. Indeed, the descriptions of vague and unpleasant sensations that are so common to Complex post-traumatic stress disorder (C-PTSD) are nothing more than attempts to describe the tremendous task of simply being present in-the-world through the body due to profound damage at the body-schema level. For the victims of such radical trauma, the body has become strange and alien. They are no longer able to feel a sense of belonging, to feel at-home within the world. Indeed, as a result of impairment at the body-schema level, the victim lives in a foreign and alien body trapped in a hostile and frightening world, which are in essence two sides of the same coin. Impairment of this type can ultimately lead to C-PTSD. The strong link between severe trauma, dissociation, SIB, and complex posttraumatic symptoms suggested in this book is certainly plausible. Severe trauma can cause fundamental damage, making it impossible for the survivor to continue being-in-the-world at the body-schema level. Due to this destruction of the living-body, the victim can no longer feel at-home within the world. Indeed, C-PTSD can be defned as a condition in which the body becomes an IT. The survivor can no longer exist at the level of the living-body or the body-schema, and as a result can no longer be-in-the-world: The world has become inaccessible. Instead, the survivor exists at the level of the body-as-object or body-image. The unbridgeable gap that ultimately emerges between body-as-subject and body-as-object can lead to the development of body-disownership. To be more precise, trauma survivors who have developed C-PTSD feel a sense of non-belonging. In practice, this means that they exist at the body- image level, while their traumatic memories are located at the body- schema level. These bodily memories threaten the survivor. Hence, to avoid their bodily traumatic memories, survivors must avoid their body-schema, causing an unbearable discrepancy between body-schema and body-image; the body-schema in effect becomes the enemy of the body-image, just as the EP is the enemy of the apparently normal personality (ANP). In turn, when body-schema and body-image clash, body-disownership can arise, leading one to identify the body as the enemy. This is the destructive mechanism that constitutes the nucleus of C-PTSD. Appendices

Appendix 1: Some Methodological Issues Scientifc work must be supported by valid data. Chapter 2 of this book is philosophical in nature and Chapters 3 and 4 rely mainly on experimental studies. However, in Chapter 5 the use of such data is simply not feasible: in the case of severe and ongoing trauma, it is simply impossible to rely on hard evidence. Clearly, we cannot examine trauma while it is occurring. To do so would be unethical. The problem becomes even more diffcult when we realize that severe traumatic experiences are characterized by dissociative reactions. Any introspective technique involves inherent problems. In order to pin down this notion let us focus on the Peritraumatic Dissociative Experiences Questionnaire (PDEQ) as a representative example. The PDEQ is “the most widely used measure of peritraumatic dissociation” (Brooks, et al., 2009, p. 154). It measures phenomena that occur during traumatic events, such as blanking out, feeling like one is on automatic pilot, time distortion, derealization, depersonalization, confusion, reduced awareness and amnesia. Yet obviously ten closed questions ranked on a scale from 1—“not at all true” to 5—“extremely true” cannot fully describe the subjective experience during trauma. In fact, it seems that we cannot even distinguish questionnaires completed by a traumatized individual from those flled in by someone using psychedelic

© The Editor(s) (if applicable) and The Author(s) 2018 155 Y. Ataria, Body Disownership in Complex Posttraumatic Stress Disorder, https://doi.org/10.1057/978-1-349-95366-0 156 Appendices drugs such as Ayahuasca. Thus we must ask what the PDEQ can really tell us about subjective experience during the traumatic event. Based on the following three main reasons, we contend that the PDEQ can tell us almost nothing:

(a) Although the PDEQ can serve as a reliable indicator that some kind of dissociative experience occurred (Steinberg, 2004), whether it provides information about the past (peri-traumatic dissociation) or the present moment (symptoms in the present) is open to argument: “recollections of peritraumatic reactions are often inconsistent over time and are potentially biased by current symptoms” (Bedard-Gilligan & Zoellner, 2012, p. 279). While it may seem that this comment is applicable to any kind of questionnaire, this remark is very specifc. It raises doubts about the ability of individuals currently suffering from PTSD and other dissociative symptoms to refect introspectively on their own experience during the trauma. (b) Individuals with PTSD and other dissociative symptoms “say that they feel locked into the past” (Ehlers & Clark, 2000, p. 334). In other words, they cannot distinguish between the present and the past moment. For them, past and present are mixed up. Under these circumstances their introspective ability is damaged. (c) In the case of peritraumatic dissociation, a traumatic event sometimes remains outside the autobiographical self. Indeed, “in persistent PTSD one of the main problems is that the trauma memory is poorly elaborated and inadequately integrated into its context in time, place, subsequent and previous information and other autobiographical memories” (Ehlers & Clark, 2000, p. 325). Clearly the survivor is not capable of introspectively examining the traumatic experience so easily.

Thus it appears that as a scientifc method, introspection presents serious problems, at the very least in the case of severe and ongoing trauma accompanied by a strong dissociative reaction. Clearly, the inability of a traumatized subject who has developed PTSD and other dissociative symptoms to look introspectively at the traumatic event is not exclusive to the PDEQ. To tackle this problem, in this study we embrace the phenomenological approach. Indeed, in this study the phenomenological approach is both a philosophical stance and a pragmatic Appendices 157 methodological tool. Let us clarify what makes the phenomenological approach such a useful methodological tool in the study of trauma. During perception, the body becomes transparent. We feel as if we are seeing the “real world.” Yet, in fact, “perception is indirect—bodily” (Richardson, 2013, p. 134), so that we perceive the world through the body. This is not to say what we perceive is our body (Gallagher, 2003); rather, in Sartre’s words, “the body is lived and not known” (1956, p. 324). The phenomenological method seeks to describe the lived bodily experience (Husserl, 1936/1970). This phenomenological reduction—what Husserl refers to as Epoché or “bracketing,” a sus- pension of judgment about the “natural world” and a return to things themselves—requires the redrawing of old beliefs, conceptions, and opinions (Gallagher & Sørensen, 2006). In addition, it emphasizes not goals themselves but the processes that enable the achievement of such goals. The method focuses on how (the pre-refective level) rather than on why and, in so doing, can “bring a person, who may not even have been trained, to become aware of his or her subjective experience, and describe it with great precision” (Petitmengin, 2006, p. 229). Furthermore, it allows us to get closer to the lived and subjective experience in general (Depraz, Varela, & Vermersch, 2003) and in particular to the traumatic experience, which occurs at the bodily level and accordingly is “stored as sensory fragments without a coherent semantic com- ponent” (Van der Kolk & Fisler, 1995, p. 12). Since in some cases the traumatic experience does not undergo tag- ging or labeling (high level cognitive processing) it remains non- contextual, “without semantic representations” (p. 8) and, consequently, outside the autobiographical self. If the traumatic experience is processed at the bodily level, it is necessary to apply a method that can reveal this bodily dimension of the experience—something accomplished naturally by phenomenology (Depraz et al., 2003; Petitmengin, 2006). Indeed, phenomenological description can provide an authentic portrayal of dissociation during trauma. As we saw, due to the diffculties resulting from the nature of the peritraumatic dissociation experience, a survivor cannot reliably complete the PDEQ. How can one refect upon past experience if this event is fragmented and outside the autobiographical self? Nevertheless, we contend that introspection can be achieved. The survivor can refect upon traumatic experience by fnding a way to reconstruct the traumatic event which was stored bodily, so that memories 158 Appendices of the traumatic event can be recovered, at least partially. The survivor requires trained guidance to avoid disrupting these memories. Without proper, non-intrusive guidance, in most cases introspection remains beyond the reach of the PDEQ as a representative tool, and indeed any kind of semi-structured interview. While the PDEQ provides no information whatsoever about the traumatic experience, the information gained in semi-structured interviews neither refects nor reveals the real experience during trauma. Indeed, a test case makes evident the most serious problem regarding the “story” spontaneously related by the interviewee in a semi-structured interview: the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). It has been argued that “although the SCID-D is not a trauma questionnaire, its ability to elicit spontaneous descriptions of trauma from patients without the use of leading or intrusive questions makes it a valuable instrument” (Hall & Steinberg, 1994, p. 112). However, at least in some cases, this spontaneous description conceals more than it reveals. Thus, it appears that patients suffering from persistent PTSD “often have diffculty in intentionally retrieving a complete memory of the traumatic event. Their intentional recall is fragmented and poorly organized, details may be missing and they have diffculty recalling the exact temporal order of events” (Ehlers & Clark, 2000, p. 324). Thus, even if the “spontaneous story” obtained in a semi-structured interview can tell us more about the experience during the traumatic events than the PDEQ—which reveals nothing about the subjective experience—nevertheless, due to the nature of traumatic experience, it is not effective for reasons that apply to any kind of interview focusing on why rather than how. Among these are:

(a) In many cases this “spontaneous story” is in fact a ready-made story. The tale has been told repeatedly on different occasions (family, friends, social services and more) and is repeated on “automatic pilot.” When relating this story, the teller obviously withholds some, perhaps even most, of the details. First, in many cases it is diffcult to reiterate the traumatic experience, because in so doing the teller experiences it again. Second, a survivor of trauma sometimes tries to protect surrounding society/family by not telling the whole story. Third, sadly in our society it is only natural to feel ashamed and hence not relate the entire story. Appendices 159

Finally, one may be afraid of over-exposure. With these factors in mind, clearly this “spontaneous story” is at best only partial. (b) We are autobiographical creatures. That is, our stories defne us (Damásio, 1999) and, in many cases, the story of traumatic events is simply too diffcult to handle. In such cases one constructs a story that one can bear. Thus it is possible that the “spontaneous story” works as a defense mechanism for the autobiographical self. (c) In some cases the traumatic experience is stored bodily and not conceptually (Van der Kolk & Fisler, 1995). For this reason, the “spontaneous story” is merely part of the whole story. In other words, when one is asked to tell one’s story, or when doing so “spontaneously,” one is usually not aware of the bodily level of experience. Indeed, survivors are “often unaware of gaps in their memory until their recollections were elicited in great detail in the course of the interview” (Brewin, 2007, p. 230).

Thus we contend that in order to reveal the bodily level of experience and consequently reconstruct the memory of the traumatic experience step by step, the survivor needs guidance. This process obviously requires appropriate caution. Even though “people can be led to mistakenly recall entire experiences through misleading interviews” (Porter & Peace, 2007, p. 435), we should not be afraid of asking what Hall and Steinberg (1994) call leading questions. By asking how and avoiding why, it is possible to guide the traumatized individual, without interfering with the content of the story. The phenomenological approach is especially suited to reconstruct- ing traumatic experiences due to two unique factors: (1) In the case of survivors who have developed PTSD, the future dimension disappears, leaving the survivor in the moment of trauma and causing the traumatic experiences to persist “in subjects’ memories, remaining highly consistent years after their occurrence” (Porter & Peace, 2007, p. 439). (2) Because the trauma is experienced and stored bodily (resulting in fashbacks), in some cases survivors can at least partially reconstruct and repair their traumatic memories. These two factors can together explain why a person who is incapable of completing introspective questionnaires or semi-structured interviews in a reliable manner may, with the applica- tion of the right techniques, be able to respond reliably and consistently to how questions posed by an experienced interviewer. 160 Appendices

All in all, Epoché appears to offer the most adequate, though obviously not the only, way to examine this radical experience. Epoché enables us to describe the pre-refective dimension of existence: to (a) describe explicitly the bodily dimension during the traumatic event; (b) distinguish between dissociation in the present and dissociation during the traumatic event; (c) classify the dissociative experience during the traumatic event; and (d) eventually turn the non-contextual experience into a contextual and accessible experience. Using this method, it may be possible, at least to some extent, to identify the characteristics of the traumatic experience. Indeed, Chapter 5 uses the phenomenological approach as a methodological tool, with regard to both victims of terror attacks and prisoners of war. With this in mind, we must now ask: “But what about Amery?” Indeed, Améry’s description was employed in the last section of Chapter 5. In order to understand the distractive mechanism that develops during severe trauma, we must fnd a way to penetrate the subjective experience. Yet the traumatic experience transcends words, as is demonstrated by the following two factors:

• The events taking place at the time of the trauma are encoded in a way that is “inaccessible” to language. The trauma is encoded at the physical level, and its factors do not undergo high-level processing, leaving them outside the realm of speech. • Trauma occurs at the level of language and therefore language itself has been traumatized. Hence the traumatic subject is unable to continue using “old” and “familiar” words, because these words have become foreign, leaving the subject forced to invent an entirely new language.

Due to this “foreignness” of and within the language, the traumatic event often remains outside the boundaries of the individual’s narrative, outside the autobiographical self. Even when victims “speak the trauma,” their story remains foreign to them, not only because of its content but also, indeed mainly, because the words themselves have become a strange entity to survivors. While bearing this in mind, let us now return to Améry’s writing. Améry (1980) remains faithful to his bodily experience. He does not use empty words but instead creates a new language rooted within the void. Thus, a close reading of Améry reveals that he created an even Appendices 161 more complex world of physical metaphors which allowed him to express the physical experience while being tortured. He understood the limitations of language in describing the experience and remained within the boundaries of the describable without resorting to descriptions full of pathos which conceal more than they reveal. For this reason, we chose to rely on Améry’s descriptions (for an in-depth discussion see Ataria, 2017).1

Appendix 2: The Phenomenology of Somatoparaphrenia The following examples are taken from interviews conducted with fve patients (Invernizzi, et al., 2013, pp. 148–149 [Appendix]):

1As noted, Chapter 6 examines the consequences of trauma and not the traumatic experience itself. Thus in that chapter we relied upon introspective testimonies. Indeed, most of the testimonies in Chapter 6 describe situations occurring in the present rather than those that took place years ago. We noted that the advantages of the phenomenological approach are particularly applicable to past traumatic incidents and less to processes occurring in the present. Despite this clear deviation from the phenomenological approach, we did not fnd any in-depth phenomenological research on self-injury. Therefore, we used existing data while noting the obvious limitations. 162 Appendices (continued) associated with the loss of real hand, not the one now attached to him, is functioning perfectly. The affected real hand, not the one now attached to him, is functioning perfectly. does not function and hence, according to pure logic, it cannot hand, however, be his own hand. This patient has lost the ability to control his hand, yet denies this fact and instead has developed an explanation according to which the affected he believes, if the hand attached to his hand simply cannot be his own. Surely, body were his own limb, he would be able to control it. and not, so it seems, due to a lack of SB O . Thus, the fact that sense limb-own - ership has not been damaged is responsible for C’s diffculty in accepting his new situation. can see how the patient’s feelings are stronger than We hand and see it as shorter. knowledge. It thus seems that C suffers from two different kinds of defcits— while the frst (cognitive and neuronal) defciency is SA, the second is associated with C’s ability to retain his delusional beliefs despite evidence. clear-cut Interpretation This patient complains that his affected hand does nothing. Thus, he is sure that his The sense of disownership in this case ensues due to denial the loss SA This patient’s sense of belief is so strong that it even allows him to look at his own . You can take it away. . You It does not move. nothing . . I’ve already told this to the other doctor. Someone left it here. It’s not mine . I’ve already told this to the other doctor. I don’t know who he was. He asked me whose hand was this one, but I don’t know who attached it to my body . Nothing. I’ve already explained it. The problem is that this hand cannot move not mine . It’s not like mine. I cannot, this hand does not move. But it is mine repeat your problem for me? Whose hand is this? E: Close your eyes and tell me if you feel when I’m touching hand. P: That’s not my hand!! E: What’s the problem with it? P: E: What did the doctor tell you? P: E: Can you move this hand? P: No, it does not move. E: Isn’t it a little bit weird to have a foreign hand with you? plus, it does nothing !! P: No! My hand is not like this! This shorter, E: What is this hand doing here with you? P: Interview (E = examiner; P patient) A second experimenter enters the room and asks: Good morning C, can you P: E: Raise your arms up, like me. Are you doing what I’m doing? P: No, I’m raising the right arm only! E: Can you show me how clap your hands? P: Appendices 163 (continued)

it does not move or Nadia ) it could not be the doctor’s represents the inherent paradox GB is facing: the tension between what knows and what he feels . Indeed, when GB is asked directly whether the hand “is … attached to your body or not?” his answer once again reveals the tension between what he knows and feels : P: No. I don’t know . If GB had simply replied ” this would not be a problem, yet he adds the words “ I don’t know. negatively, Evidently on some level GB knows that the thesis he is attempting to construct is somewhat problematic. has distortedhas affectedhis views he way the (top-down) hand— It’s a female hand … thin and dryit’s not mine , it doesn’t look like mine. My hand is more . It’s not mine. yours… I have no need for it. It doesn’t work … work like the right one . In thus describing his experience, he is in effect saying that he has lost control over the affected hand. Note the following paradox, however: If it is a women’s hand ( It belongs to the nurse — cognitive processes hand. This indicates strong top-down infuences. O rdinarily, (both bottom-up and top-down) provide reciprocal feedback, which generates The fact that the subject is less sensitive balance and enables us to operate in reality. to information entering from the world (bottom-up) testifes to power of top-down processes that enable him to disregard changing information coming from the world. The subject is not really concerned whether this is a woman’s hand or a man’s hand. Thus the subject is driven mainly by his new set of beliefs, enabling him to disregard information coming from the outside (bottom-up). So long as the subject can disregard bottom-up information, he can easily retain these false beliefs. This is a vicious circle that reinforces itself. affected limb. This denial becomes unbearable precisely because the sense of limb-ownership has not collapsed—at least completely. and reality itself, that is, between top-down processes and bottom-up processes. When discussing his affected hand, GB uses the word “could.” This word perfectly Interpretation GB strongly believes that the affected hand is not his own, a belief so strong that it GB has lost SA towards the affected hand as is refected in his answer to the doctor: GB’s sense of disownership arises due to his denial the loss SA towards the In other words, disownership is the result of a confict between one’s set beliefs Nadia forgot it and I Nadia forgot need for it. It doesn’t work . Maybe you’ll be able to get it work. a bit. I would like to understand why it does not move or work the Yes, right one. Mine or yours. It’s a female hand. It belongs to the nurse… but it’s wearing my pajamas … it’s strange. it doesn’t look like mine. My hand is more thin and because it’s not mine , it doesn’t look like mine. My hand is more Yes, dry . Impossible. Let’s try… No, I’m not doing it right, can’t you see? I can make clapping . noise but I’m not really Because there was this hand here and I thought that wanted to give it back to her. She cannot work without it. Poor Nadia. wanted to give it back her. hand is this? it’s not one, but when I pinch that hand can’t feel I’m pinching. O bviously, mine. It’s yours . The examiner moves the pajamas out of GB’s line vision and says: Whose I can feel if you pinch the right GB touches the hand and says: I don’t know. E: Where is your real hand? P: Here on the bed. E: If this hand isn’t yours, can I take it away with me? f course! If you want it, I will give it to as my gift, since have no P: O E: Are you sad about having that hand with you? P: E: What is this? P: It could be my hand. E: Could? Whose hand is this? P: Interview (E = examiner; P patient) E: Look at this hand, is it attached to your body or not? P: No. I don’t know … do not feel it. E: The nurses told us you woke up last night and called them. Why? E: Look at me and do the same. Raise your hand. P: It’s the same. I’m raising only my right arm, the good one . E: Do you want to move this hand away? Wouldn’t you be sad without it? E: Do you want to move this hand away? Wouldn’t if it was mine, but it’s not . P : Yes, you prefer that this hand was not so close to your body? E: Would P: P: E: Show me how you can clap your hands. P: 164 Appendices (continued) strong that he denies any association with the affected limb/side. resting on his stomach while the doctor moves it in front of his face. The subject cannot accept his situa - allows the subject to twist reality completely. tion and creates an alternative reality in which the hand attached to him could be someone else’s limb. because of what because of what he does not know knows, or more accurately, The subject knows that he will always he knows that does not want to know. he prefers not . Yet be paralyzed: I don’t think will able to move them anymore to know this information. This leads to the development of a whole set beliefs based on the desire not to know what he knows. Indeed, the information pursues and also manages him, leading to the creation him, much like traumatic memory, of a new world based upon the denial reality. Interpretation MA serves as a perfect sense of belief is so example of a strong sense of denial. MA’s This belief allows MA to twist reality completely—he describes his affected hand as This example reveals that disownership is rooted in a sense of belief so strong that it The subject develops disownership This can also be expressed in another way. Yes, but the same is true left side of my body is for my left leg. The entire Yes, paralyzed. Do you think I will ever be better? don’t able to . move them anymore left hand in front of That hand does not move . The examiner brings MA’s his face. you joking? Why should it be mine? My hand is different, of course. Are Yours I always keep it on my stomach. not so heavy and it’s there, E: Why are you here? P: I had a stroke. E: How are you now? All right? P: No, I can’t move this arm. left arm? E: Your P: E: Try to put your arms up like this. P: E: What is this thing in front of you? P: A hand. E: Whose hand is this? P: Yours! E: Mine? Are you sure? sure, whose hand is it supposed to be? P: Yes E: And where is your left hand? P: O n my stomach. Can’t you see? E: So this hand isn’t yours. P: No, my hand is on stomach and cannot move. E: Whose hand could this one be? P: E: This is my right arm and this is the left. It couldn’t be mine. P: Then maybe it’s the doctor’s hand. He surely needs it. Call him. Interview (E = examiner; P patient) Appendices 165 (continued) identifes her left hand, yet she is sure that it is not her hand. In addition, Miss S is very it clear that she wishes the doctor would take away her left hand ( Surely, it away ). Thus becomes apparent that disownership, in this is not mine. Take case at least, is accompanied by a feeling that the subject needs to dispose of disowned hand. and hid his hand in my bed as a joke! … examined me before Someone working here E: Where is your real hand? P: I suppose he took my hand away and gave me this bad one! Go ask him!). Indeed, this reveals that disownership is accompanied by a strong belief that the hand is not one’s own, a exceeds knowledge and logical thinking. Denial of the loss SA creates a new kind of logic that distorts reality. Interpretation Miss S has lost her SA towards the affected hand ( it does not obey ). She Clearly, The story of Miss S is clearly not rational (E: If it yours, whose hand it? P: Try to place your arms like this, as if you were holding up a tray. She raises Try to place your arms like this, as if you were holding up a tray. her right arm. Someone working here examined me before and hid his hand in my bed as a examined me before Someone working here joke! Give it back! What a joke!! I would prefer my hand; this one is too fat and puffy! E: How are you, Miss S? P: Not fne, it does not work . E: What does not work? P: This arm (she touches her left hand), it does not move, obey . E: I understand, but if touch you there, can you feel it? I do not know why but it does obey . P: Yes, E: Why are you here? P: For a stroke. E: E: Can you do that? P: No, the other hand ( left ) is not working, it does obey!! E: What’s that? P: A hand of course. E: Whose hand is it? P: I do not know . E: Don’t you know? Whose hand could it be? it away . it is not mine. Take P: Surely, E: If it is not yours, whose hand it? P: E: Where is your real hand? P: I suppose he took my hand away and gave me this bad one! Go ask him! Interview (E = examiner; P patient) 166 Appendices him to deny reality and construct an impossible situation: his hand is in fact the the doctor can have three hands. O n some doctor’s hand. In this new reality, even when Yet C is aware of the improbability of this theory. Mr. level, however, he does not abandon his story. confronting this problem directly, ership mechanism is a system that specializes in denying reality and in creating a top-down alternative that is not dependent upon information arriving from the bottom up. Interpretation C portrays disownership accompanied by a strong sense of belief that allows Mr. The general conclusion here is particularly important. At the core of the disown - (after placing his left hand near the patient’s hand): Can you choose your own hand among these hands? The main problem is with the entire left side of my body. I cannot feel it or The main problem is with the entire left side of my body. move it anymore. E: Hi, Mr. C, why are you here in this hospital? E: Hi, Mr. P: I had a stroke while I was on holiday. E: What are your problems now? P: C., look at this. What is this? E: Mr. hand . P: Your E: My hand? Are you sure? of course. It couldn’t be mine . P: Yes, E: Why? P: It looks more well-groomed than mine. E: From zero to ten, how sure are you that this is not your hand? P: Ten. E: How sure are you that it is mine? P: Nine and a half. E: both yours . P: They are E: (after placing both his right and left hands near CP’s hand). And now? P: They are yours. E: All three of them? P: Yes. E: Don’t you think there are too many hands for me? are a polyp! P: (smiling at the examiner). You Interview (E = examiner; P patient) Bibliography

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A B abuse being-in-the-world, 15, 16, 20, 24, childhood abuse, 105, 106, 123, 25, 30, 121, 122, 124 133 be-in-the-world, 7–9, 23, 24, 122, sexual abuse, 84, 102, 105, 108 126, 142 aggression, 103, 140 belong/belonging, 2, 4, 8, 10, 16, aggressive, 60, 132 22–25, 29, 38, 61, 63, 71, 73, alien/alienation, 8, 16, 82, 104, 122, 92, 118, 120, 134, 135 135 blame, 64, 123, 132 altered state of consciousness, 19, 30, Blanke, Olaf, 10, 41, 43, 73 63 blind, 32, 60, 93 Améry, Jean, 1, 7, 11, 91, 92, 95, 96 body amputation/amputee, 2, 31, 66–70 as-object, 2, 9, 13, 16, 22, 23, 45, anger, 102–105, 120, 123, 140, 141 48, 70, 74, 83, 95, 109, 121, anosognosia, 59, 60, 63, 64, 66 124, 136, 143, 144 anxiety, 8, 37, 43, 104, 114, 131 as-subject, 2, 13, 17, 22, 23, 45, 48, arms, 35, 67, 94 70, 81, 121, 124, 125, 136, attack, 5, 10, 84, 88, 96, 109, 117, 143, 144 126, 141 -disownership, 2, 9–11, 42, 60–62, autobiographical self, 106, 113 65, 74, 89, 91, 94, 97, 142, automatic, 2, 19, 22, 54, 87 144 autoscopic hallucination (AH), 37, -image, 2, 4, 9, 10, 19–21, 23, 38, 45 55, 61, 65, 66, 71, 73, 74, autoscopic phenomena/autoscopic, 91, 109, 122–124, 126, 136, 10, 37, 41 141–144 map, 4, 69, 73

-schema, 2, 4, 5, 9, 11, 19–22, 24, detached, 1, 4, 41, 42, 44, 58, 96, 25, 29, 33, 45, 54, 58, 61, 119, 137 65, 66, 68, 71–74, 83, 91, detachment, 38, 85, 89, 119, 124 111, 121, 122, 124, 125, 138, de Vignemont, Frédérique, 30, 109 142–144, 146 disembodied/disembodiment, 37–39 body integrity identity disorder disgust, 102, 124 (BIID), 2, 3, 10, 58, 66, 68–73, disownership/disownership toward the 109, 111, 142, 144 entire body, 2, 10, 36, 42, 44, 56, boundary(ies), 16, 20, 23, 31, 36, 93, 59, 60, 62, 65, 68, 70, 72–74, 104, 115, 125, 134 91, 97, 110, 126 dissociation/peritraumatic dissociation/dissociative, 81, 82 C dissociative identity disorder, 37, 44, captivity, 89, 140 117 complex posttraumatic stress disorder dissociative subtype of PTSD, 132, (C-PTSD), 8, 9, 11, 126, 132, 133 133, 136, 140, 144 distorted, 83, 114, 132 concentration camps, 8, 91, 114, 133 double, 2, 20, 37, 38, 55, 71 control, 20, 32, 53, 54, 61, 63, 65, 85, 87, 89, 91, 101, 109, 120, 141 E coping, 96, 125 Ehrsson, Henrik H., 42, 44 coping mechanism, 101, 103, 104, eliminate, 109, 111, 118, 139 106, 108, 119 embodiment, 37, 41, 43, 49 corporeality/corporealized/corporeal- emotion, 8, 24, 102, 115, 118, 133 ization, 93, 135, 136 emotionally detached, 87 Cotard delusion/Cotard’s delusion, emotional numbness, 87, 137 45, 47 enemy, 63, 95, 109, 139, 144 exist, 4, 9, 22, 23, 42 existential helplessness, 92, 93 D death, 1, 14, 96, 131, 141 defense mechanism, 81–84, 117 F delusional, 39, 62, 68 father, 108, 110, 114, 120 delusional belief, 61, 71 fear, 120, 140, 141 depersonalization, 10, 44, 45, 47, feeling of agency, 4, 54, 65, 66, 68, 104, 117, 132, 138 71, 74 depression, 37, 102, 104, 110 fght or fight, 86 derealization, 104, 117, 132 frst-person perspective (1PP), 3, 9, desire for amputation, 68, 69 10, 14, 41–43, 46, 49, 72, 73, destroy, 14, 64, 97, 111, 139, 140, 109, 124, 125, 136 144 fashbacks, 8, 104, 107, 131, 138 Index 187 fesh, 1, 16, 17, 35, 94, 95, 115, 116, K 119 knowing body/knowing-body, 6, 14, foreign, 56, 135 18, 32, 35 freeze/frozen, 86, 87, 107, 117, 139 knowing-how, 7, 136 frustration, 60, 102 Körper, 2, 13, 23

G L Gallagher, Shaun, 2, 19, 21 Leder, Drew, 9, 22, 24, 82, 134, 135 Gestapo, 91, 95 Leib, 2, 3, 5, 13, 23, 45 guilt, 102, 104, 118, 123 limb, 20, 31–36, 56, 59–71, 73, 90, 109, 142 limb-disownership, 3, 4, 9–11, 58, 62, H 63, 65, 73, 74, 88, 91 hand(s), 8, 10, 14, 16, 31–33, 35, lived-body, 2, 32, 45, 70, 120, 125, 53, 57, 63, 67, 87, 94, 108, 110, 136 117, 121, 134 living-body/living-body, 5, 9, 13, 35, head, 7, 40, 89, 108, 119 111, 122, 136 heautoscopy, 37, 38, 45–47 location, 20, 41, 42, 94, 109 Heidegger, Martin, 134 loneliness, 102, 104 helplessness/helpless, 10, 16, 63, 84, long-term-body-model (LTBM), 85, 92, 93, 96, 102, 120 32–34, 69–71 Herman, Judith Lewis, 8 home, 8, 24, 25, 38, 40, 44, 92, 116, 134 M hostility, 11, 63, 66, 140, 142 maladaptive mechanism, 104 humanity, 17, 97 memory(ies), 8, 81, 106–109, 111, 112, 114, 126, 131, 138, 139, 144 I intrusive memory, 8, 107, 131 Ian Waterman (IW), 9, 20, 34, 73 traumatic memory, 106, 111, 121, I-can/I-cannot/I-Can-Not, 22–24, 138, 139 135 Merleau-Ponty, M., 5, 9, 13–20, 32, isolation, 89, 141 81–83, 93, 113, 121, 123 IW. See Ian Waterman (IW) Metzinger, Thomas, 39, 41 minimal phenomenal selfhood (MPS), 41, 43, 44 J minimal self, 54 James, William, 29 misoplegia, 63, 64 Janet, Pierre, 81 mood, 24, 25, 57, 132, 134, 143 Jaspers, Karl, 24 188 Index

N prisoner of war (POW), 10, 83, 88 Nazi, 91, 114 proprioception, 20, 24, 29 negative heautoscopy, 46, 47 prosthesis/prosthetic limbs, 10, neglect/emotional neglect/physical 31–35, 49, 69, 70, 72, 90, 91 neglect, 59, 60, 102, 105, 106 pure object, 13–15, 121–123, 136 nightmare(s), 8, 87, 107, 131 numb/numbness, 16, 87, 90, 92, 115, 118, 119, 137 R rage, 139–141 rape, 5, 84, 110, 116 O Ratcliffe, Matthew, 8, 22–25, 44, 134, objectifcation/objectivization, 16, 93 135 other person/others, 8, 16, 22, 23, reduction, 1, 23, 95, 104 39, 42, 46, 57, 61, 66, 93, 102, relief, 102–104, 108, 110, 112, 120, 104, 107, 110, 112, 114, 122, 140 123, 132, 134, 135 representation, 2, 19, 33, 48, 70, out-of-body experience (OBE)/out- 107 of-MY-body experiences/out of resistance, 91, 93, 96, 123 body (as-object) experience, 2, 9, Rubber Hand Illusion (RHI), 10, 31, 13, 22, 37, 39, 45, 84 33, 42, 44, 62, 142 over-presence, 1, 10, 62, 65, 73, 144 ownership, 1, 3, 4, 29–36, 42–45, 48, 55, 58, 60–63, 65, 66, 68, S 70–73, 83, 84, 90, 120, 125, Sartre, Jean-Paul, 122–124 144, 146 self, 16, 24, 37, 38, 41, 45, 54, 59, 67, 97, 104, 125, 132, 137 self-cutting, 101, 140 P self-destructive, 102, 105, 106, 132 pain, 1, 21, 70, 89, 94–96, 102, 104, self-harm, 64, 101–103, 106, 109, 108–112, 115, 116, 118–121, 110, 114, 117, 124, 125, 141 125, 134, 135, 139, 140 self-hatred, 103, 104, 111, 122 paralysis, 59, 138 self-injuring behavior/self-injuri- perception/perceive, 2, 5–7, 9, 13, ous behavior (SIB), 11, 70, 97, 17–19, 21, 23, 24, 60, 82, 83, 101, 103–106, 108, 110, 112, 123, 135 114–121, 124–126, 139–141, perceptual feld, 14, 15, 21, 122 143, 144, 146 perpetrator, 120, 122, 140, 141 sense of agency (SA), 3, 10, 32, 49, phantom limbs, 68, 69 58, 65, 87, 89–91, 93, 119 phenomenal feld, 22–24, 32, 135 sense of body ownership (SBO)/too posttraumatic stress disorder (PTSD), strong sense of body ownership, 8, 82, 84, 107, 131–133, 140 3, 10, 11, 25, 29–31, 33, 34, practical knowledge, 5, 6, 18 36, 40, 42, 43, 45, 47, 48, 54, prisoner, 10, 83, 88, 89, 92, 140 56–58, 60–62, 65, 72–74, 83–85, Index 189

87–91, 108, 119, 125, 142, 144, touch, 15, 20, 31, 46, 93, 124 146 tradeoff model, 121 sense of self, 38, 93, 95, 96 transparency/transparent, 33, 36, 69 sensorimotor loops, 5–7, 9, 29, 71, trauma/traumatic event, 5, 7, 8, 10, 122, 136 21, 81–84, 86–88, 90, 93, 97, separate/separation, 3, 16, 24, 39, 45, 105, 107, 109, 111–117, 121, 46, 84, 94–96, 102, 105, 121, 126, 131–133, 136–142 125, 135, 137, 138, 143, 144 traumatic bonding, 141 severe and prolonged trauma, 104, trauma type II, 8, 104, 141 114, 115 trust, 92, 93, 124 silence/silent, 114–116, 120, 138 twofold structure/dual structure, 3, 9, skin, 16, 32, 43, 112, 115, 116, 120 15, 47, 93, 121 Slater, Mel, 47 solitary confnement, 55 somatoparaphrenia, 2, 3, 10, 11, 58, U 59, 61–63, 65, 68, 71, 74, 88, unreal, 38, 48, 83, 105, 115 91, 109, 144 stress, 8, 21, 57, 82, 104, 108, 118, 133, 140, 141 V structural dissociation, 11, 117, 126, Van der Kolk, Bessel A, 7 137–140, 142 victim, 1, 7, 9, 87, 90, 92, 94–96, subject, 9, 14, 15, 17, 22, 24, 33, 35, 106, 113, 115–117, 122, 123, 37, 38, 47, 60, 72, 74, 102, 103, 125, 136, 140, 141 121, 133, 146 voice, 38, 112, 115, 116, 119 subjectivity, 14, 83, 94 void, 94, 113 subject-object, 16, 17, 48 suffers, 20, 60, 89, 144 suicide/suicidal behavior, 68, 101– W 103, 105, 111 war, 10, 83, 88 survivor, 8, 9, 21, 23, 84, 94, 106, world, 3–9, 13–19, 21–25, 48, 83, 92, 111, 113, 114, 132, 133, 136, 93, 97, 113, 116, 120, 122, 124, 137, 139, 140, 142, 144 125, 134, 135, 139, 144

T Z tension, 10, 17, 102, 104 Zahavi, Dan, 54 testimony, 1, 34, 38, 62, 83, 84, 87, 102, 108 third-person-perspective (3PP), 2, 9, 13, 19, 47, 109, 125, 136 tool/defective tool, 9, 31–33, 55, 60, 89, 90, 104, 109, 117, 124, 143 torture, 1, 83, 91–93, 95, 96, 125 total loss of control, 61, 89