Common pathways in mental imagery and pain perception: an fMRI study of a subject with an amputated arm

The present paper reviews data from two previous studies in our laboratory, as well as some additional new data, on the neuronal representation of movement and pain imagery in a subject with an amputated right arm. The subject imagined painful and non-painful finger movements in the amputated stump while being in a MRI scanner, acquiring EPI-images for fMRI analysis. In Study I (Ersland et al., 1996) the Subject alternated tapping with his intact left hand fingers and imagining "tapping" with the fingers of his amputated right arm. The results showed increased neuronal activation in the right motor cortex (precentral gyrus) when tapping with the fingers of the left hand, and a corresponding activation in the left motor cortex when imagining tapping with the fingers of the amputated right arm. Finger tappings of the intact left hand fingers also resulted in a larger activated precentral area than imagery "finger tapping" of the amputated right arm fingers. In Study II (Rosen et al., 2001 in press) the same subject imagining painful and pleasurable finger movements, and still positions of the fingers of the amputated arm. The results showed larger activations over the motor cortex for movement imagining versus imagining the hand being in a still position, and larger activations over the sensory cortex when imagining painful experiences. It can therefore be concluded that not only does imagery activate the same motor areas as real finger movements, but also that adding instructions of pain together with imaging moving the fingers intensified the activation compared with adding instructions about non-painful experiences. From these studies, it is clear that areas activated during actual motor execution to a large extent also are activated during mental imagery of the same motor commands. In this respect the present studies add to studies of visual imagery that have shown a similar correspondence in activation between actual object perception and imagery of the same object.     

Impasse and the interpretation of perversion

This article presents a case study of a year of psychotherapeutic work by a female and male therapist with a 14-year-old boy born with ambiguous genitalia. His mother was also present in the sessions at the request of Zak. We describe the early trauma surrounding Zak's birth and the subsequent desertion of a violent father. We present the catalogue of medical interventions he received to re-construct his genitals. Now at the age of 14 years Zak is entering into a chemically induced puberty. His mother had a version of an internal couple at war, where the male was viewed as useless and with suspicion. This view served to distort her capacity to bear Zak's condition and dovetailed with his phantasy of a monstrously violent and destructive male. Thus the artificial shove into manhood for Zak was filled with terror. The induced puberty was felt more like an attack and he acted out through resistance to intervention and non-compliance. This organisation created in him a state of thoughtlessness and despair, which we propose parades itself as a ‘secondary handicap’ (Sinason, Mental Handicap and the Human Condition, Free Association, London, 1992). Our joint work as a couple with Zak and his mother stood in opposition to their internal structures and provided an experience of a different kind of coupling: an opportunity to observe a cooperatively working couple who helped give words to the anxieties they brought. We trace Zak's attachment to and internalisation of a thinking couple, which paralleled both his ability to become more expressive and a reduction in acting out his aggression. The work aimed to promote in Zak a level of emotional development that was commensurate with his physical development. The construction of genitals and a lifetime of testosterone injections alone will not allow Zak to grow into the man he can be. We will attempt to explore the basis of these structures to demonstrate that the work provided the opportunity for Zak to reflect upon and express his terror, and to turn to other people to seek support, help and advice.     

Fonagy and Freud. Psychological versus psychic reality

Peter Fonagy and Mary Target present their Playing with reality theory as a developmental theory centred on the concept of psychic reality. This paper compares Fonagy and Target's use of the concept of psychic reality with Freud's original concept. It is argued that the concept of psychic reality has been redefined from delineating a psychic reality stemming from the unconscious to denoting a kind of conscious or preconscious psychological reality characterized by an experience of equality between the internal and the external worlds. The theoretical discussion is illustrated by being applied to eating disorder pathology, which by Fonagy and colleagues is described as associated with thought processes characterized by psychic reality.     

Self-harm by omission: A question of skin containment

Abstract

This paper explores the phenomenon of ‘self-harm by omission’ and its relationship to other kinds of self-harming behaviour and to disturbances of psychic skin functioning (Bick, 1968 Bick, E. 1968. The experience of the skin in early object relations. International Journal of Psychoanalysis, 49: 484–486. [PubMed], [Web of Science ®] , [Google Scholar]). Process material from work with a patient ‘Kate’ is introduced to illustrate and clarify the matters under consideration. The conceptual framework provided by psychic skin theory is described, with particular reference to the defences of ‘toughening’ and ‘porosity’ and their relevance to understanding different kinds of self-harm. Arising from this work, suggestions are advanced with regard to further development and an extended range of application of a ‘skin containment’ conceptual framework.     

Making room: Developing reflective capacity through group analytic psychotherapy – in the analyst and in the group. Part one

Abstract

This paper is in two parts. This, the first part, traces the inter-related development of trainee group analyst and training group during the first nine months of the group's life. The influence that personal group analytic psychotherapy, supervision and theoretical learning have on the trainee are also considered in relation to the development of the group and its members, many of whom suffer from narcissistic and borderline disorders. The metaphor of ‘making room’ is used to explore the efforts of analyst and group to contain the chaotic, confused and unbounded projective identifications of its members. In this way, amidst the crowded turbulence of the group, a space begins to open up in which, slowly and painfully, the capacity for reflection may emerge.     

Counter-narratives in context: The role of the organisation and broader culture in psychic splitting among South African survivors of intimate partner violence

Chronic trauma, shame and psychopathology, as well as the association between them, are acutely understudied, both in South African and internationally. The focus of this article is on chronic trauma of a particular kind, intimate partner violence (IPV) and the development of a specific form or shame-related psychopathology, the splitting of self and how this splitting may be further facilitated or exacerbated by the contexts in which people live. The (counter) narratives of three women are presented. These (counter) narratives demonstrate the presence of both a concealed and shameful authentic self, and the socially conforming projected false self, two polarised parts of the psyche. It is argued that the organisational context, a shelter for survivors of IPV, which has a strong ethos centred around advocacy and human rights and which promotes a strong message of personal empowerment and agency, may unintentionally exacerbate the psychic split in women who have been subjugated at a broader (predominantly patriarchal) cultural level their whole lives. Participants’ resistance narratives were often characterised by inconsistencies and contradictions which oscillated between supporting mainstream cultural narratives and organisationally driven, active resistance against the cultural context from which they came. However, resistance narratives often felt thinly veiled and inauthentic, which is one of the problems with interventions in resource constrained settings which are necessarily time-limited. To fully and completely counter the cultural message that has been the focus of participants’ lifelong gendered socialisation, long-term and in depth interventions at organisational level are needed. These ideas are not only relevant to the South African setting, but have wider application internationally.     

Agency and pain: An exploration

The notion of agency has become particularly prominent in social‐science writing. This article identifies some of the weaknesses in the ways it has been employed in contemporary anthropology. It criticises the assumptions of self‐empowerment, responsibility, and constructivism that are held to be essential to moral agency in much of that usage. Present‐day conceptions of agency in this literature introduce—whether intentionally or not—a triumphalist vision of history. Drawing on recent neuro‐physiological research, religious history and ethnography, it focuses on pain in order to think about agency in other than triumphalist terms. Triumphalist versions of agency, the article argues, are not only inherently questionable, they also distract our attention away from the need to understand how different traditions articulate the idea of living sanely in a world that is inevitably painful.     

The Failure to Contain: How Persecutory Anxieties Contribute to Noncompliance in Adult Patients with Congenital Chronic Pain Conditions

ABSTRACT

Patients with sickle-cell disease suffer from lifelong pain. Many prefer to receive emergent rather than managed health care, which results in these people being termed “noncompliant.” This paper explores the contributing factors of such noncompliance in the adult patient with painful chronic illness. In the earliest stages of development, internal pain is attributed to external origins, and the effects of this on the psyche are analogous to those of physical abuse. When the infant's pain cannot be contained, projective identification and persecutory anxieties become deeply ingrained. Interventions that focus on healing from trauma and building trust are preferable to those which most value immediate compliance, as the patterns of behavior are so firmly entrenched.     

Strategic and Automatic Threat Processing in Chronic Musculoskeletal Pain: A Startle Probe Investigation

Attentional bias research with chronic pain samples has yielded conflicting results. In the present investigation the startle paradigm was used to test the postulate that fear‐based mechanisms play an important role in attentional biases for pain‐related threat in chronic pain. Participants, including 31 individuals with chronic musculoskeletal pain and 20 healthy controls, completed a startle task designed to measure attention to different types of words (neutral vs sensory pain vs affective pain vs health catastrophe) presented at different levels of cognitive processing (strategic vs automatic). Measures of fear‐based individual difference variables, including anxiety sensitivity and fear of pain, were also completed. Startle amplitudes and latencies to acoustic startle probes that followed word presentations were recorded. Data were analyzed with repeated measures ANOVAs and correlational analysis. Significant between‐group differences were found indicating that, relative to chronic pain participants, healthy controls had higher startle amplitude index scores for health catastrophe words. There was also a trend among patients with chronic pain for greater startle amplitude index scores for strategic presentations of sensory pain words. In the automatic condition, all participants demonstrated a lower startle latency index for sensory words relative to both affect and health catastrophe words, suggesting participants had more difficulty disengaging from affect and health catastrophe words or were more avoidant of sensory words. Correlational analyses indicated that startle response indices for words related to health catastrophe became more pronounced for chronic pain patients as anxiety sensitivity and fear of pain increased. Implications and directions for future research are discussed.     

THE “AS‐YET SITUATION” IN WINNICOTT'S “FRAGMENT OF AN ANALYSIS”: YOUR FATHER “NEVER DID YOU THE HONOR OF”… YET

The author proposes a new hypothesis in relation to Winnicott's “Fragment of an Analysis”: that as early as 1955, in the case described in this text, Winnicott is creating the paternal function in his patient's psychic functioning by implicitly linking his interpretations regarding the father to the Freudian concept of Nachträglichkeit. The author introduces an original clinical concept, the as‐yet situation, which she has observed in her own clinical work, as well as in Winnicott's analysis of the patient described in “Fragment of an Analysis” (1955).