Effects of trauma on body perception and body image
Maurizio Stupiggia
When an abusive event occurs, the ability for self-identification as our inner mirror in which we can usually recognize ourselves and allow us to feel our body and our thoughts as our own, crashes down. In short, everything about ‘feeling at home’ is taken away. Freud (1919) used to define this kind of unease with the word unheimlich, literally meaning ‘not-at-home’, usually translated to ‘non-familiar’. This is a central feature about living with abuse: the feeling of being taken away from oneself, ripped out, as if by magic by an unknown, tremendous power that can transform a person into an outsider. In addition, the person can be robbed of the ability to control and manage their comportment under unforeseen situations. In essence, the abused person lives in a constant sense of exposure, as if his inner drama were public knowledge. What a paradox!
To confirm this paradoxical situation, we can think about the etymology of umheimlich in heim: the ancient root of the word ‘home’, and we can find it in a different word, geheim. Es ist geheim means ‘it is a secret’ and in this sentence, we can understand the close connection between feeling at home and the possibility of keeping a secret. The experience of abuse immediately breaks down one’s inner protection, and the person is bound to be feel great risk. “I feel like I cannot find a way to hide my ‘disability’”, one of my patients used to say during the first few therapy sessions. ‘It’s like everybody knows there’s something wrong with me. I’m always tense, never relaxed, careful of how I move, watching what others do, trying to constantly understand if I’m acting well or doing something wrong’.
When a secure and safe inner place is missing for a person, they live in a constant state of unrest and concern, and the body shows symptoms that make it look like a little scared fawn, or an animal who doesn’t want to be approached. In addition, there is another result of this exile: abuse influences the patient’s self-knowledge, relegating the patient himself into a kind of cognitive vagueness, fearing their own emotional awareness, and body sensations.
‘I am terrorized, but don’t know about what’ said one of my patients during our first session, ‘I’m often scared, but not quite sure of what I fear’. These words are emblematic of some patients’ state of uncertainty and reveal the separation between corporeal sensations and cognitive functions. For instance, a person can sense a deep muscular tension re-enacting the fear, but without connected congruent mental representations. Such a separation is very common in these cases: memory has split in two, one side physical and the other side mental and the reunification of these components is the only hope of healing, otherwise our patient’s already fragile and disorganized mindset is at great risk. ‘When I speak about that, I start feeling bad, not feeling relieved at all’, say patients after they share their story, ‘even worse than before, I feel heavier’. Reporting to a therapist usually comforts a patient, but not in the case of abuse. Even talking about it increases a sense of anguish, and the patient often asks to suspend and turn to another topic. However, in such a situation, a body-and-breathing-based therapy only would not be enough: during therapy sessions with abused patients, they report that they experience a lack of corporeal identity, a gradual loss of self-consciousness and an empty feeling inside. ‘If I keep on shaking my arms – some patients say – I feel kind of weird . . . as if they don’t belong to me . . . like I’m losing them . . . I feel dizzy, almost like fainting’.
These kinds of sentences are common during therapeutic sessions: a therapist who is treating a sexually abused patient has to work with symptoms that are difficult to categorize: in some cases, a patient might report that doing rapid and strong arms movements, might have the uneasy feeling that his arms belong to someone else, or at least from his wrist down. In other cases, a patient might report that it’s impossible to raise their tone of voice when the situation demands, even if the situation is not important, or thereafter notice that using a higher tone of voice, or even a low scream, they would be terrorized by their own voice as though it came from somebody else, within or outside themselves. In other words, when the patient moves differently or if arousal increases, they experience that their body is no longer their own.
From a phenomenological point of view, the threatening feeling that is experienced when a patient is listening to the internalized traumatized voice, the ‘Selves’ begin to split within the patient. It becomes obvious that this split is connected to the abuse experience, although it’s not so obvious how to relieve this sense of alienation and reunify even a minimum sense of identity.
Chiara came to psychotherapy at a time of despair. After so many years of difficulty in having sexual intercourse and intimate moments with her previous partners, she was recently experiencing a totally new relationship with her new mate, Antonio, who’s sweet, caring and in love; he doesn’t mind too much about the troubles Chiara faced in the past and he’s very respectful during their awkward moments in bed. Everything seems to be going smoothly, until Chiara found out that she was pregnant. Antonio was on top of the world, as he had been hoping for it to happen for a long time and they had already talked about it.
But the day after finding out she was pregnant, Chiara woke up in a different mood: she felt kind of weird; she couldn’t stand Antonio’s physical proximity and felt disappointed in seeing his joy. She tried to conceal her negative emotions, and tried to think of a medical explanation, blaming her hormonal changes. Indeed, hormonal changes are part of pregnancy, but not exactly the way Chiara thought; what has dramatically changed is how she perceives Antonio. Only a few days previously, he was like an angel that had fallen from the sky, but now he’s a demon, who introduced his gift into her womb, like an invader burning his mark upon conquered territories. Antonio’s joy sounded like a disgusting victory-cry in front of a humiliated enemy. ‘I can’t sleep anymore, because I’m afraid of my belly demon, I’m worried that he can get out and catch me at night’, Chiara reported.
During one of our therapy sessions, Chiara said that she still has her wits and realizes that she is probably delirious, but she can’t help it. I realized that Chiara was experiencing a typical distortion of reality, which is very different from a psychotic delirium, but no less pervasive.
Chiara’s experience was very common amongst abused women: they conflate their invasive traumatic experience with a possible pregnancy and cannot bring it to term because it’s viewed as an illness, like a violent experience. Chiara’s hatred for Antonio was tempered only by a voluntary termination of pregnancy, twenty days later, after going through emotional hell that affected both of their lives. It took another four years of hard emotional work for Chiara to fulfill her dream of having a baby; an example of how abuse can influence the ability for the couple to accomplish their own biological desire of having a child. These difficulties can therefore disrupt different life stages important to an individual and for a couple, and the possibility to live in harmony with nature. It is also a clear example of detachment between body and emotional processes, generating scary and delusional thoughts.
The dissociative symptoms of detachment refer directly to an individual’s experience of feeling alienated from their emotions, from their body, from the usual sense of their own identity, and from the sense of familiarity (van der Hart, Nijenhuis, and Steele, 2006). Dissociative symptoms and some types of somatoform symptoms have common roots in dissociative processes, a concept that Nijenhuis (2004) has proposed to introduce the diction somatoform dissociation. Patients with some types of somatoform disorders have demonstrated high levels on scales that measure dissociation and present dissociative symptoms coexisting with the somatoforms symptoms. (Farina, Mazzotti, Pasquini, and Mantione, 2011). In addition, there is evidence that physically and sexually abused people have a higher risk of developing somatoform disorder (Paras et al., 2009).
Furthermore, Barsky (1992) describes a cognitive style called ‘somatosensory amplification’ (p. 28), which can be applied to many patients with somatoform disorder (SD). Patients with somatoform disorder often exhibit a heightened focus on their own bodies, perceiving their bodily complaints as illness quicker than healthy people do. The term central sensitization (Bourke, Langford, and White, 2015) has recently been used to describe a neurobiological process which assumes that symptom onset is associated with a hyper-responsive neural network in high-risk individuals. Patients with SD rate normally innocuous stimuli as painful stimulation due to an alteration of the brain’s neural network and perceive their complaints as illness and thus display augmented bodily attention (Barsky, 1992).
The insula is known to be important for pain processing (Fitzek et al., 2004) and in tests where painful stimulation was administered (Sawamoto et al., 2000); activation of the insula has been reported primarily for cutaneous pain rather than visceral pain. However, it seems that central mechanisms like central sensitization might have a higher impact than a peripheral one. This unspecific network of higher brain functions was also called a neuromatrix (Melzack, 2001). This network, previously called painmatrix (Iannetti and Mouraux, 2010) is not specific for pain as it is active in various conscious processes (Melzack, 2001). The results seem aligned with the hypothesis of central sensitization (Bourke et al., 2015) as mentioned above (Perez, Barsky, Vago, Baslet, and Silbersweig, 2015).
We just discussed the relevance of the insula in somatoform disorders as it is connected to dysfunctional perception of pain and to somatosensory amplification. Another crucial aspect of those disorders is the distortion of body image. The insula is just one of the places where body maps are generated. We have also seen that in people with dissociative PTSD, the insula is involved in de-regulation, since the insula is necessary to perceive the internal sensations of the body, map them in terms of the body, and is an essential bridge between the motor areas of the mirror neurons and the amygdala.
Forms of body depersonalization also modify body image, sometimes clamorously, and can be observed in eating disorders and in body dysmorphic disorder (Nijenhuis, 2004). One distinctive aspect of the brain is in the prodigious skill to create maps. When the brain creates maps, it informs itself. Action and maps, movement and mind are part of an endless cycle. The human brain is a born cartographer and the cartography begins with the mapping of the internal body. These are probably the mind’s primordial constituents based on afferent nerves coming directly from the body.
It is interesting to observe that body maps are also essential and primordial components which constitute for the mind the very first revelation that its organism is alive. Briefly, while the brainstem nuclei would ensure basic level sensations, the insular cortices would provide a more differentiated version of them and most importantly, they would be able to put sensations into relation with other cognition aspects based on the brain activity taking place somewhere else. For all these reasons, we can say that clinical work deals with body sensations, body image and the integration between the two.
In short, while the dissociative phenomenon of detachment corresponds to a lack of integration between higher structures of the brain, and the deficit in the regulation of emotions is due to the lack of top down modulation of the neocortical structures of the limbic system, some types of dissociative somatoform symptoms seem to show an integrative deficit of bottom up modulation between the centers of the visceral brain and neocortical areas. In other words, the disconnection of the experience in the somatoform dissociation would be due to the lack of integration of the information from the lower nerve centers, branches of the afferent and of the somatovisceral memories, with the information processed with the maps in higher brain related to the representational capacities of consciousness and reflexiveness. In particular, somatoform dissociation leads to a lack of integration between consciousness and explicit somatovisceral memories that form the basis for the perception of the body, and the representation of what may appear to the others.
Usually in the field of psychotherapy, clinical pictures are traditionally traced to a single defensive reaction of the mind that would protect it from overwhelm and intolerable pain caused by trauma. The brain will also dissociate from consciousness the memory of the event, its meaning, its value of reality to avoid the experience of the pain. This explanation of the linear relationship between trauma and dissociation, despite its undeniable plausibility, is not so evident: many cases show an inadequate vision of the relation between trauma and dissociation, the latter as a purely intrapsychic defense from the mental pain caused by the former.
Some studies (Cantor, 2005; Liotti, 2011) suggest for example, that the type of exchange of affection between a disorganized attachment figure and a child is the primary cause of this dissociative dynamic. The healing will not depend so much on the clinical work of the reworking of individual traumatic memories, but from the fact that such work is carried out in specific interpersonal contexts capable of allowing the recovery of a sufficiently safe and organized experience (Liotti, 2011). In a secure attachment the dissociative processes resulting from trauma are not the source of particular relevant dissociative symptoms, but only transient changes of the integrative functions of memory and consciousness (arising from the defense system operations designed to reduce the physical pain and inhibit the higher brain activity) (Andrews, Brewin, Rose, and Kirk, 2000; Cantor, 2005) In order to understand more fully this complexity, we must explore a dynamic that is both intrapsychic and intersubjective; where intersubjectivity is viewed first and foremost as intercorporeality (Gallese, 2005).
Maria, who was 37 years old when she consulted me, was aware of a traumatic child abuse incident which occurred when she was between 7 to 10 years old. At the age of 11 Maria started complaining about abdominal pain, diagnosed as chronic irritable bowel syndrome. Since she was 14, she had been suffering from a thyroid dysfunction that made her gain weight rapidly and in an uncontrolled way. When she was 22, she started having sudden fevers that weakened her for long periods of time. Doctors thought the symptoms were similar to rheumatoid arthritis with unknown origin.
Maria rarely had romantic relationships, excluding a very long relationship with a priest that never turned into a sexual relationship, but there had always been an ambivalence between them regarding friendship and something deeper. Maria reported that she often felt as if her body didn’t belong to her; sometimes she vomited unexpectedly or would become paralyzed by muscular heaviness while in difficult situations. In the moments of paralysis, she feels ‘weird’ and ‘not in control of her arms and legs’. This is a significant symptomatology that does not appear to correspond to any reasonable medical diagnosis, but that can be included under the somatoform disorders category.
During one of the first sessions, Maria started talking about her history of abuse, but as soon as she got to the core of her story, she stopped and reported that she was in a high agitated state. I asked her to stop and put her right hand on her chest, where she was feeling agitated, and breathe gently; I did the same and we gradually catch the same breathing rate, which becomes like a sort of gentle wave. Maria began to calm down: her face gets more relaxed, her shoulders relaxed and she can take a couple of deep breaths. She seemed to be better, but suddenly, I see the contorted look on her face when she says, ‘It’s absurd! I can see you, but I see your penis, in front of me’. Her whole body got extremely stiff and rigid with tension, and the atmosphere became tougher and suspended, like a harbinger of imminent danger.
I stayed still, only moved by my breathing, until I caught a subtle hand gesture that looked like a distancing movement, trying to push away something or somebody in front of her. I started nodding and mirroring her gesture, encouraging her to widen it and continue that sensorimotor pattern of constructing boundaries (Stupiggia, 2013). Meanwhile, I bent my head to the side and leaned on the backrest of my armchair to show a distancing motion. After 1 minute of a significant silent dance, I noticed Maria’s gentle breathing start again, her shoulders relax and a peaceful expression on her face. ‘Now everything returned to normal, you look like your usual self, I feel better’.
A week later, Maria reported that since the last session, she felt ‘more energetic, more alive’, especially in her arms and hands. She talked about her moments of generic fear that she suffered in the past (not necessarily related to the abuses), and began to show the same kind of agitation she experienced during our previous session, this time including a choking knot in her throat. We start the same work over again (self-contact and breath mirroring with me), and got into a relaxed state exactly the same way as before, but this time, almost in the same moment, she said that she could not feel her feet and legs up to her knees. She became afraid and her body tensed up again, showing the anaesthesia/analgesia and movement disorder states, which are typical of somatoform dissociation symptoms (Nijenhuis, 2004).
I started to slow down my movements, my rate of speech, and lowered my tone of voice, asking her to look at her legs and feet and make physical contact with those parts of her body. Maria, wide eyed, looked at her legs and feet as if they are foreign objects; it seemed like a never-ending moment until she finally stretched her shaking hand out on her leg, in an extremely slow motion. It felt like a very long time, and, while I observe the scene, I think about how she must have felt when she was a child, when her uncle used to touch her little body!
Similar to our last session, I also made contact with my legs, trying to imitate her movements in a sort of partial mirroring. After several minutes in this state, Maria seemed to be slowly feeling confident in her legs; her breathing rate gradually connected with the movements of her hands and her whole body became involved in a tender self-massage. ‘I have never touched myself in this way . . . I have always hated my body . .. or feared it. And I have never allowed anyone to touch it! I had almost forgotten to tell you that I’ve had a numb sensation in my feet for so many years, that I was almost unable to feel my shoes or the ground beneath me’. Maria looked very surprised by her new sensations and continued touching her legs and feet.
We spent a little more time feeling such a new experience until I noticed that the excitement level reduced. I then suggested to her to take a step further: ‘Close your eyes half way, and try to visualize the image of the external shape of your entire body and put it in front of you. Then take your time . . . in your own way . .. keeping in touch with your sensations . . . continue touching your body with your hands, . . . try to let your newly perceived body into that pictured silhouette’. Maria focused on her task, her face seeming to follow the imagination process for a full minute until she took a deep breath that shakes her gently. ‘I feel better . .. I feel safe . . . protected’.
Two years have passed since these two sessions when Maria addressed her past traumatic events, and after these 2 years of continued therapy with me, her life has significantly changed: she feels calm, has new friends, she feels more productive at work and has begun a loving relationship with a man. Above all, she has changed her relationship with her body and no longer has anesthetic, numb feelings in her feet and legs. In addition, she has started to try the pleasure of touching and caressing herself and feels surprisingly complete: no longer has that terrible feeling of living in a ‘foreign body’.
Body psychotherapy treatment with Maria was obviously complex and full of obstacles, moving backwards and forwards. This chapter highlighted the core aspects of these sessions, illuminating the first part of the work to describe the type of care provided for symptoms of SD.
In the two sessions described above some guiding principles of body psychotherapy treatment were applied. First, Polyvagal Theory (Porges, 2009) guided the treatment by decreasing arousal whenever Maria came into contact with emotional content that was too intense and disturbing. Second, the principles and methodology of Sensorimotor Psychotherapy (Ogden, Minton, and Paine, 2006) helped to focus attention on Maria’s sensations and movements and to wake up the bottom-up process that forms the basis of treatment. In addition, the methodology of key-gesture (Stupiggia, 2013) helped to detect, amplify, intensify and then turn microgestures, that represent internal resources, into new sensorimotor patterns that were not yet known by Maria.
A third aspect, the importance of body image (which in these cases were compromised), became a key part of the treatment. A small example is represented in the latter part of the second session, when I asked Maria to imagine her body and to connect it with the body sensations in that moment. The body image is a crucial aspect of the construction in personal identity.
Fourth, the importance of doing all of this inside a relational frame which, as Liotti (2011) says, is a big factor in the production of dissociative disorders and is also the main therapeutic factor.
Fifth, and closely linked to the relational dimension, is the way of working with mirroring, which becomes the clinical application of mirror neurons (Gallese, 2005) in their interpersonal paradigm of neurobiological foundations. Dance/movement therapist Marian Chace first used the term mirroring when describing her clinical work during the 1940’s and 1950’s (Chaiklin and Schmais, 1993). Chace distinguished mirroring from simple imitation which is a duplication of the external shape of movement without the emotional content. She had the clear intuition that answering movement in similar forms can build a strong and deep relationship and can dissipate the feeling of loneliness or apartness.
In relation to the sessions illustrated, mirroring was applied in a specific way in body psychotherapy; not only the partial or almost total mirroring of the movement of the patient, but also the complementary participation of the therapist’s involvement in the process. In the first session there is an example of this that we can define as ‘following mirroring’, a concept which I am defining for this type of technical work. When Maria freezes because of her hallucinatory vision of the therapist’s penis, the therapist tries to tune in to the immobility of Maria and her respiratory rate while she, at the same time, produces a series of small movements that are representative of gestures trying to distance themselves from a hazard or a hostile person. Seen from the outside, this looks like an interactive dance, where one person (the therapist) follows and adapts to the movement of the patient, thus producing an obvious effect and conduction process of the dance and of the management of the process, on the part of the patient (Gallese, 2014).
It is important that the patient leads this interactive dance and above all it is essential that she is aware of having a clear effect on the therapist. In the cases of traumatized patients, we work by concentrating on the inversion of the past traumatic situation of the patient, who had to obey the oppressive power of someone else (or event) that was overwhelming for the individual. In this form of mirroring the therapist comes in and acts as a subordinate by mirroring partly the movements of the patient, and partly adapting the movements into a complementary or subordinate way.
This technical variation allows the patient to recover the power lost during the traumatic event, and to lead and take control of the process: for these reasons I decided to define this technical process ‘following mirroring’.
In summary, trauma can rip a person from their body, and cause disembodiment which can alter the capacity to tolerate intense experiences; alter the ability to regulate emotional states through the use of the body, distort body image and tear apart the capacity for relationships. The result is an individual who is distanced from themselves, from their body, and from healthy relationships with others. The body psychotherapist’s job is to help the patient ‘return home’ and reconnect the story and their body into a new dimension of intimacy with others, but above all, with themselves.
Andrews, B, Brewin, C. R., Rose, S., and Kirk, M. (2000). Predicting PTSD symptoms in victims of violent crime. Journal of Abnormal Psychology, 109, 69–73.
Barsky, A. J. (1992). Amplification, somatization, and the somatoform disorder. Psychosomatics, 33, 28–34.
Bourke, J. H., Langford, R. M., and White, P.D. (2015). The common link between functional somatic syndromes may be central sensitization. Journal of Psychosomatic Research, 78, 228–236.
Cantor, C. (2005). Evolution and post traumatic stress: Disorder of vigilance and defence. London: Routledge.
Chaiklin, S., and Schmais, D. (1993). The Chace approach to dance therapy. In S. Sandel, S. Chaiklin, and A. Lohn (Eds.), Foundations of dance/movement therapy: The life and work of Marian Chace (pp. 75–97). Columbia, MD: Marian Chace Memorial Fund of the American Dance Therapy Association.
Farina, B., Mazzotti, E., Pasquini, P., and Mantione, G. (2011). Somatoform and psychoform dissociation among women with orgasmic and sexual pain disorders. Journal of Trauma Dissociation, 12(5), 526–534.
Fitzek, S., Huonker, R., Reichenbach, J. R., Mentzel, H. J., Witte, O. H., and Kaiser, W. A. (2004). Event-related fMRI with painful electrical stimulation of the trigeminal nerve. Magnetic Resonance Imaging, 22, 205–209.
Freud, S. (1919). Das Unheimliche [The Scary]. Vienna: Imago.
Gallese, V. (2005). Embodied simulation: From neurons to phenomenal experience. Phenomenology and the Cognitive Sciences, 4, 23–48.
Gallese, V. (2014). Bodily self, affect, consciousness and the cortex. Neuropsychoanalysis, 15(1), 42–45.
Iannetti, G., and Mouraux, A. (2010). From the neuromatrix to the pain matrix (and back). Experimental Brain Research, 205, 1–12.
Liotti, G. (2011). Attachment disorganization and the clinical dialogue: Theme and variations. In J. Salomon and C. George (Eds.), Disorganization of attachment and caregiving (pp. 383–413). New York: The Guilford Press.
Melzack, R. (2001). Pain and the neuromatrix in the brain. Journal Dental Education, 65, 1378–1382.
Nijenhuis, E. (2004). Somatoform dissociation: Phenomena, measures and theoretical issues. New York: W.W. Norton.
Ogden, P., Minton, K., and Pain, C. (2006). Trauma and the body. New York: W.W. Norton.
Paras, M. L., Murad, M. H., Chen, L. P., Goranson, E. N., Sattler, A. L., Colbenson, K. M., . . . Zirakzadeh, A. (2009). Sexual abuse and lifetime diagnosis of somatic disorders: A systematic review and meta-analysis. Journal of American Medical Association, 302, 550–561.
Perez, D. L., Barsky, A. J., Vago, D. R., Baslet, G., and Silbersweig, D. A. (2015). A neural circuit framework for somatosensory amplification in somatoform disorders. Journal of Neuropsychiatry Clinical Neuroscience, 27, e40–e50.
Porges, S. (2009). The polyvagal theory: New insights into adaptive reactions of the autonomic nervous system. Cleveland Clinic Journal of Medicine, 76(2), 86–90.
Sawamoto, N., Honda, M., Okada, T., Hanakawa, T., Kanda, M., Fukuyama, H., . . . Shibasaki, H., (2000). Expectation of pain enhances responses to non-painful somatosensory stimulation in the anterior cingulate cortex and parietal operculum/posterior insula: An event-related functional magnetic resonance imaging study. The Journal of Neuroscience, 20, 7438–7445.
Stupiggia, M. (2013). From hopeless solitude to the sense of being-with. International Body Psychotherapy Journal, 11(1), 25–40.
van der Hart, O., Nijenhuis, E. R. S., and Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: W.W. Norton.