BIID:Body Integrity Identity Disorder

As recently presented in the book "The Man Who Wasn't There" by Anil Ananthaswamy, is not real.

First, let me explain by "not real". We got to go down a philosophical pathway first and note a distinction between two types of pathology. There are pathology's (or diseases) that are genetic and exhibit irreversibility. And then there are diseases that exist because of some underlying condition that the person isn't aware of (i.e blood pressure, diet, stress) that can otherwise be changed.

Anil Anathaswamy and others who claim that BIID is a "neurological disorder" and thus requires a medical treatment (removal of the body part the person wants to remove) are advocating what seems to me to be an insanely extreme position - and ironically enough (from an Indian writer) Anathaswamy doesn't seem to recognize the influence MIND - that is, how the experiences human beings have in their everyday interactions with other human beings can influence the neurobiology of the brain and the homeostatic balance between "self in relation" (the states we enact when we communicate with others) which is situated in the frontal and dorsal temporal areas, and the areas of the brain stem which regulate homeostatic processes (i.e the various factors influencing blood flow, breathing, etc) - can have on the body; and, I might add, ones sense of relation towards a body part is not at all different from the other ways the mind can go wrong.

Lets explore some of these other ways: anorexia nervosa, spasmodic dysphonia and gender dysmorphia

The first one is a disorder of how someone experiences their own body. The cause, of course, is the overwhelming influence (as experienced by the anorexic) of the significance society ascribes to body image. Causally speaking, some aspect in the anorexic's early relational environment (as between mother and her, father and her, individual siblings and her, and the emergent properties at higher levels) makes her vulnerable to succumbing to the influence society places on body image. I want to make clear that I am speaking probabilistically: when certain combinations of relational circumstances come together (say a gene for being high reactive and a mother who yells and screams) the likelihood of a certain phenotype (or consequence in behavior) is made either high or low.

Anytime anorexia appears, it can be said to have these certain relational conditions "scaffolding" the appearance of the phenomena in question. The end phenomenological (or the psychologically experienced) state is the sensation that ones body looks fat. I don't know what that's like and neither do you: it requires the presence of certain preconditions to 'make apparent' the "reality" that one is overweight, even though one may in fact be desperately underweight.

The second condition is one I myself once dealt with. I suffered a severe relational trauma at 13 which occurred again at 15 and 16. The result was post-traumatic stress disorder which, since it was caused by bullying, is better described as "developmental trauma", also known by other theorists as "complex trauma".

The issue of psychological or emotional trauma is perhaps best understood in terms of energy flow through the nervous system. Our nervous system is built to process a certain rate of information. When were relaxed and yet focused - a necessary mental state for effective socializing - information passes between humans with very high fidelity. On the other hand, when we feel threatened, our brain switches from what the neurophysiologist Stephen Porges calls the "social engagement system" to the "fight-flight" system. In neuroendrincology, this system is better known as the hypothalamic-pituitary-adrenal axis.

Whenever were shocked into defensive reaction, our brain releases a chemical from the hypothalamus (CRH) which causes the pituitary gland to release adrenocorticotropin into the blood stream; this then causes the adrenal glands (which sit atop the kidneys) to release adrenaline and cortisol. Cortisol, in turn, breaks down glucose which is then used to power mitochondria in cells; cell activity for the energy required to mount an effective defense response. This is basically what's happening when were "stressed" by the world.

When being bullied, I realized early on that I couldn't speak. What I heard whenever I attempted to speak was the presence of anxiety; an unconscious effort, compulsively enacted, to 'fix', or control, or do something that would make the bullying end. Repetition. The longer the threat lasts, the more consequential the effects on brain cells and the architecture of inter-cellular activity. Eventually, you brought to a state of mind of compulsive alertness to the now generalized relational threat: alert to the cues of others, in face, voice, of movement, that indicates disapproval. I found myself operating as if 'from without', seeing myself as a "shameful object", deserving disdain; the external viewpoint is what happens under relational trauma; the other party, the other perspective, begins to dominate your attention. In evolutionary logic, this is precisely what we should expect from examples in lower phyla: organisms adapt by modifying their internal organization. In complex multicellular organisms, these changes are coordinated to correspond to the information coming in from the visual system. Such as running away, fighting, or freezing when the two other responses aren't available or aren't possible. This, also, is basically what the simplest cells do: they pull away from noxious chemicals; likewise, they draw closer to useful chemicals.

Spasmodic Dyphonia is the belief that the raspy, stressful effort to speak is caused by an unrecognized neurological disorder; I, as well as many other psychologists and neuroscientists (such as Robert Scaer) believe a "disease" such as this is a consequence of relational trauma that occurred in the early years of development. I see early years because the belief that spasmodic dysphonia is a real thing (brain, or even larynx related) gains its force from a lack of episodic memory to make sense of it's presence. Because I suffered bullying, I know the contexts that brought this state out of me. Neurologically, the voice - the organ that felt the stress when one felt the need to protest the abuse - remains tentative and withdrawn.

Should we infer from a brain scan that the brain is causing a voice issue? Or should we instead trace the dots backwards and recognize the obvious contingency between social reality and the effect it can cause in neurobiology.

Finally, lets get back to body integrity identity disorder, with reference, this time, to what I've explained about the way emotional trauma builds anxiety and over-reactivity into brain processes. This occurs because, again, in a normal evolutionary context, the body is meant to 'burn' off the energy being provided by the stress response system (which, it bears mentioning, is inherited from evolutionary older species); but in our very unusual evolutionary environment, we often find ourselves stuck, in a job, without a context that can help us process our emotions without feeding them through, again and again, as rumination and paranoia about the self and it's world.


Here's an example. Imagine being 3 years old and witnessing a car accident. All around you people are screaming;loud noises all around you activate the stress response system. A women cries for help. Scared, you instinctively turn to where you last saw your mother, but she isn't there. You can't see here. You look and look. You breathe heavy, you start crying, wailing, mommmmmmmmy, wherrreeeee arrrrrrrreeeeee yooooouuuuuu. You quickly turn around and trip on the curb in front of you, you fall down and bang your knee on the cement. Your legs bleeding and you begin to cry harder.

In the brain at these same exact moments, the stress elicited by the context at hand spurred the HPA Axis into activity. It's revolution in the brain, each moment of fear and anxiety, is fed through and magnified from moment to moment. The brain is on maximal "high alert", feeling threatened and enacting a defense behavior that may elicit help attention from helpful adults. In particular, I want to highlight the 'social' parts of the brain as well as the parts that deal with meaning and narrative. "Mommy" is missing, and the loss is felt by the child as terrible: felt with such totality because psychological individuation has yet to happen.

The hitting the knee at the same sequence of time brought into the chorus of activity the area of the sensory cortex that processes knee sensations. The knee - in pain - is being 'incorporated' into a sequence of neurological events that's presently processing an existential sensation of emptiness of self; the mother - the source of identity for a child this age - is missing, and so in a sense, is the child. Hitting the knee brings the 'knee' into the experience of existential absence.

The read psychosomatic disorders exists is perhaps ultimately a manifestation of homeostatic balance. The brain may seek to "unload" certain experiences in different and sometimes anomalous ways. Normally, psychological trauma is processed and the person is able to return to balance without much residue on present functioning. But very often, when the intensity crosses a certain threshold, psychological trauma exerts disastrous effects on consciousness via the deleterious influence of cortisol on neurons. The self is instantly made disordered in some way. For some, it can be the voice (as it was for me); for others, their body (gender dysmorphia). But trauma is apparently very diffusive. A trauma can be 'linked' and contained, as it were, by the fact that a simple thing like a knee bang occurred at the same time one experienced trauma. Just as in other traumatic experiences (this is a science, called 'traumatology') episodic memory is 'deleted' by the power of cortisol, but procedural, or implicit memory, often stays. This is the core feature of post-traumatic stress disorder and there is very good reason to believe that a body part mapped by the brain which was experiencing trauma may 'retain' the existential, embodied sensation of being 'alien' from the body.

This is hard to understand for us because the idea of someone not 'owning' a body part seems strange, so it must, of course, be real, in this day and age of brain science. But we shouldn't rush to such a conclusion when a relational event (trauma) can provide a core 'basis' for the evolution - key word here, the perceptual state of the adult is the not same as the 4 year old, 5 year old, etc; perceptions change as our brain evolves more complex ways of analyzing an experience: for the adults Anathaswamy describes, they spent many years deluding themselves about an experience, which, understandably, they couldn't give narrative sense to (and thus resolve the anxiety: traumatic stress follows because of a lack of episodic clarity,) and thus grew more and more estranged from.

Now, of course, there is the question: so if not amputation, psychotherapy?

Yes psychotherapy. But also, not just any psychotherapy. You need a therapist who can pay attention to the global and systematic effects of interpersonal communicative displays in interaction, and also gain a sense of the individuals history to 'flesh out' out a narrative structure that can go along with this procedural symptom

This, I hope, will one day become a rule in a neurobiologically based psychotherapy: when a person is relating to some aspect of their experience in a dissociated way, assume trauma. As mentioned above, traumatic experiences are recorded differently than normal experiences. Because of the large amounts of circulating cortisol (possibly other stress chemicals as well may have toxic effects on cellular structures) and the particular role the hippocampus and adjacent structures play in 'working memory', what is felt phenomenologically by the traumatized person as 'dissociation', may well be the mental manifestation of neurons being destroyed by too much of a certain chemical.

What does this mean? It means the entire experience as neurologically coded is imperfectly processed. The physiological and affective feelings seem to persist, but without much memory of an event. In particular, I'm thinking of those children who are abused or neglected who fail to develop coherent self-schemas, and thus fail to experience themselves in any normal or healthy way.

Therapy would seek to locate some plausible "building" block from the persons past, and from that past, construct a coherent self narrative that can "take in" and absorb the meanings associated with the body part.

On another note, in this day and age of brain 'mapping', I find it unbelievable that brain scientists don't pay attention to the psychodynamic processes psychoanalysts pay attention to. It's ridiculous. The thoughts and feelings we ascribe to events and the meanings they hold about our past relationships, these are brain events; not only that, as many neuroscientists already acknowledge, a coherent sense of self, a sense of "I know where I am" in one's conceptual self-space, is very important to the whole idea of the self narrative.

Anxiety is tamed when we are able to contextualize or given meanings to our experiences. But when an experience seems nebulous (without an episodic memory) the procedural experience (a sense of numbness, or distance) can generate thoughts that canvass every aspect of the experience, until, over time, a relationship with the body-part has been formed - and also very much 'enbrained' - by countless instances of brooding, ruminating, and suffering from the thoughts and feelings you're having.

I must also stress how unethical it was for Anil Anathaswamy not to pay attention to the difference between psychotherapy's; even more so, to not know about all the progress being made in the field of psychotraumatology, which for example, allows us to study the symptoms of the present (a feeling towards a limb) with reference to catayzing events in the persons relational past.

Lastly, since the self is made in relation, it can only be remade, or remolded, by relationships. Intensive psychotherapy would be the only means to "create" new relational self states as, in terms of systems theory, existing 'ways of being' practiced thousands of times form deeper "troughs" than activities only performed a few times. So, psychotherapy, weekly, can help CREATE A NEW RELATIONSHIP (does the foundationless nature of the mind bother you?) between a person and his affectively infused body part.

But why don't we know this? Enter insurance companies, who want "quick and effective" solutions that work more on 6 week schedules, rather than the more necessary "as long as possible" schedule. This is what skews results.

And on an even more final note, claiming tihs to be a real condition that warrants surgery is a dangerous idea to throw out there, as people, especially anxious people, are liable to be suckered in by the gravity of the statement, and brood upon it, until they too develop the conviction that they have "always felt this way".

The mind is inherently dissociative. Each new revolution of consciousness codes differently, but often follows predictable pathways. At our core is a defensiveness, because dissociation is all about paying attention to things that are relevant to survival; in our abstract minds, this also means ignoring feelings that generate shame or anxiety: homeostasis works 'throughout', physically and psychodynamically.