Body Disownership in C-P.t.s.d.

B O DY
DISOWNERSHIP
I N C O M P L E X P O S T T R A U M AT I C
STRESS DISORDER
Yo c h a i A t a r i a
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
Library of Congress Control Number: 2018937874
© The Editor(s) (if applicable) and The Author(s) 2018

This work is subject to copyright. All rights are solely and exclusively licensed by the
Publisher, whether the whole or part of the material is concerned, specifically the rights
of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and
information in this book are believed to be true and accurate at the date of publication.
Neither the publisher nor the authors or the editors give a warranty, express or implied,
with respect to the material contained herein or for any errors or omissions that may have
been made. The publisher remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Cover image: © Richard Wareham Fotografie/Alamy Stock Photo
Printed on acid-free paper
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 first hand with those who
have suffered such extremes, and who witness to that first-person expe-
rience 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 phenomeno-
logical difference between the body-as-subject or lived-body (Leib) and
the body-as-object (Körper) is a basic distinction informing Ataria’s anal-
ysis. 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 paral-
lel, 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 sym-
bol “≈,” which means more or less equal or approximately equal. This
is an important sign of qualification. 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

significant 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-reflective aspects
are tightly integrated. It’s difficult to pull them apart, either phenome-
nologically or neurologically. In terms of neuroscience, both experiences
depend upon sensory integration processes (some of which are likely cor-
related 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 mov-
ing, but I am not the agent of that movement (in such cases, no effer-
ent 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 compli-
cated, 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 cen-
tral 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 confined 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 per-
ceptual, motor, and affective dimensions, we find deep transformations
in the extremes of the kind of trauma associated with war, violence, rape,
torture, and even the slow effects of solitary confinement.
In connection with traumatic effects, one might not think of the unu-
sual experiences of autoscopy, heautoscopy, and out-of-body-experiences,
and specifically experiences that have been replicated experimentally both
by direct neuronal stimulation and by the fascinating use of virtual real-
ity (this is the important work of Olaf Blanke and colleagues). But this
is just what Ataria does. He shows the resemblances of these phenom-
ena, 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 identified as a
tool to inflict 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 specific 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 Confinement: Phenomenology, Psychology, and Ethics.”
At this conference, I raised the ideas put forward in this book for the first
time. Not only do I want to thank Shaun for inviting me to this confer-
ence. 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 com-
ments. 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 con-
tribution 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 cru-
cial 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 first 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 flesh 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
identifies 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 suffer-
ing: “When the whole body is filled 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 phe-
nomenological levels and to demonstrate that this mechanism is respon-
sible 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,
defined 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 defined 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 defined 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 organi-
sational processes (body-schema) with (b) higher order, top-down bod-
ily 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 artifi-
cial. 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 phenomeno-
logical world, while body-image is more cognitive
Having clarified 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 first-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 contra-
diction 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 first-order contradiction between SBO and SA at the body-

schema level is insufficient for limb-disownership to develop. Rather,
a second-order contradiction is also necessary. To understand this sec-
ond-order contradiction, we must first differentiate between feeling
and judgment—between knowing this is my body and feeling it. This
incongruity can be defined 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 first-order
contradiction at the body-schema level. Nevertheless, the first-order con-
tradiction alone is not sufficient for limb-disownership to occur.
Ownership Agency
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 mecha-
nisms are detached from one another does not mean they do not engage
in dialogue. Indeed, they work together on a regular basis; their syn-
chronization 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 perspec-
tives, according to which the mind, the body, and the world are consid-
ered 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 definition of trauma (e.g., by the American Psychological
Association), this book defines 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-reflective expectations are
confirmed 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.
Influenced 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 phys-
ical movement and interaction” (p. 1). More precisely, perception is the
exercise of sensorimotor knowledge, which can be defined 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 charac-
ter of input” (O’Regan & Noë, 2001, p. 84).
6 Y. ATARIA
To perceive, we require the pre-reflective ability to master our move-

ments 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-reflectively) the outcomes of our
actions, our ability to master a situation is weakened. Our practical knowl-
edge is damaged, rendering us incapable of tuning into sensorimotor con-
tingencies 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 knowl-
edge. Scholars generally tend to emphasize the human ability to adapt—
to learn how to handle the world—while wearing inverting glasses. Yet,
during the first 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 cer-
tain 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 find 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 first-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 struc-
ture. Our ability to remain systematically tuned into our environment
based on a set of laws or sensorimotor contingencies enables us to per-
ceive. Hence, damage to this sensorimotor circuit weakens our ability to
perceive.
In perceptual terms, though only in perceptual terms, we may com-
pare trauma to the experience of someone watching a Ping-Pong game
on a wide screen. This individual, who is wearing inverting glasses for
the first 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 first wore the inverting glasses: “On the first day of wear-
ing 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 sufficient 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 con-
struct a new system connecting between expectations and actual possi-
ble outcomes, thus modifying the knowing-how structure. In the long
term, however, the outcomes can be devastating because the very struc-
ture of the sensorimotor loops has become embedded within trauma.
Considering this in terms of someone who cannot see the world with-
out 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 individ-
ual 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, flashbacks, 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 Specified (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 par-
ticular (a) emotion regulation difficulties; (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 pris-
ons, 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 sim-
ple PTSD but victims of ongoing trauma at times also develop character-
istic 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 expe-
rience and activity, an opening onto a significant world filled with poten-
tial 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 inter-

fering 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-reflectively 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 defined 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
defined 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 chap-
ter 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, first-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 com-
pletely 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 phe-
nomena. In addition, it examines the phenomenology of depersonaliza-
tion and, based on this analysis, argues that despite being flexible, 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 inves-
tigation 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 first-order contradiction can lead to a sec-
ond-order contradiction between body-schema and body-image. More
specifically, 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 feel-
ings 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 sufficiently 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 somatopara-
phrenia and BIID, this can result in limb-disownership. The same mech-
anism may be activated with respect to the whole body. Indeed, Améry’s
(1980) description of his feelings while being tortured reveals the phe-
nomenology 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 argu-
ment 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 mecha-
nism 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 finds 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 cog-
nitive 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 sub-
jects 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 under-
stand the world around us through the living-body; the lived-body
shapes and is shaped by the environment in which it acts.

https://doi.org/10.1057/978-1-349-95366-0_2
14 Y. ATARIA
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 reflect on the essence of subjectivity, I find it bound

up with that of the body and that of the world, this is because my exist-
ence 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 con-
cretely, is inseparable from this body and this world. The ontological world
and body which we find 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 comprehen-
sive 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 first-per-

son 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 per-
ceptual field as other objects do. In fact, our body enables us to examine
other objects in the perceptual field 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 fields (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 field fundamentally differs from all
other objects. Our body transforms the perceptual field 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 field 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 field 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 flatter 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
field. (Merleau-Ponty, 2002, p. 369, my emphasis)
The perceptual field 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 field 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 field 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 infiltrating 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 unfinished 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 flesh 2: The per-
ceiving 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 flesh late in his writing.

16 Y. ATARIA
and invades reality. Merleau-Ponty uses the concept of flesh 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 exist-
ence of a subject but rather indicates that the boundary between subject
and world is fluid. 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 flexible, a sense of helplessness is liable to
develop. Indeed, this is demonstrated by the cases of two patients suffer-
ing from schizophrenia (De Haan & Fuchs, 2010), S. N. and L. N. The
former describes the following experience: “My skin is extremely thin, espe-
cially 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 equi-
librium. 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
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 reflect
itself; it would be an almost adamantine body, not really flesh, 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 ques-
tion, 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 some-
thing 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 specifically, perceiving is the exercise of sen-
sorimotor knowledge, which O’Regan and Noë (2001a) refer to as knowl-
edge 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 defined 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-reflective; hence, as
O’Regan (2010) argues, it remains beyond words. The following exam-
ple may clarify the matter:
Consider a missile guidance system. When the missile is following an air-

plane, 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 sys-
tem 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).

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 defined 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 percep-
tual monitoring” (p. 24). Whereas the body-image can become the con-
tents 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) auto-
matic, bottom-up sensory and organisational processes (body-schema)
with (b) higher order, top-down bodily and perceptual representa-
tions (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 define
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 reflec-
tion 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 field. 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 defined. In contrast, at the body-schema level these boundaries are
less clear, less easily located, and more flexible 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 flexible 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 influence body-image. Such
pathological cases strongly support Gallagher’s double dissociation prin-
ciple. With this in mind, let us examine Ian Waterman’s case.
At the age of 19, Ian Waterman suffered a severe bout of gastric flu.
During this illness, his body produced antibodies to fight the infec-
tion, which then attacked his nerves. As a result, Ian suffers from dif-
ferentiation 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 walk-
ing 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;
5. have confidence 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 first-person egocentric perspective upon the
world.
Clearly, A fundamental question is how can Ian move his body lack-
ing 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 con-
sciously and continually maintained,” because, “if he is denied access
to a visual awareness of his body’s position in the perceptual field, or
denied the ability to think about his body, then, without the frame-
work of the body-image, the virtual body-schema ceases to function”
(p. 52).4 Under such circumstances, Ian’s body would become an inten-
tional object—an obstacle and a burden. The same may be true in states
defined as liminal, among them fatigue, pain, sickness, certain patholo-
gies, and other stress situations.
Through an analysis of this case, Gallagher provides some critical obser-
vations regarding the double dissociation between body-schema and body-
image which are highly significant to the present discussion. As we will see
later on, Ian’s phenomenology can improve our understanding of post-
traumatic symptoms. Survivors of severe and ongoing trauma suffer from
deficits 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 field. 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 (percep-
tions, beliefs, and attitudes) toward the body can prenoetically shape the structure of the
perceptual field. 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 reflected in how we
are thrown into the world, as Ratcliffe (2008) notes: This change is expe-
rienced as “a changed relationship to the world as a whole, an alteration in
the possibility space that one finds oneself in” (p. 124). Indeed, any shift
in the equilibrium between body-as-subject and body-as-object immedi-
ately 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 significant pro-
ject in which one was previously immersed, a loss of practical possibil-
ities that the world previously offered” (p. 125). Indeed, the world is
a field of possibilities—a phenomenal field in which we know what we
can achieve. What I-can-(or cannot)-do defines the phenomenal field 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 ani-
mals, 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 field in terms of motor inten-
tionality at the body-schema level, an “actional field” (Leder, 1990,
p. 18). Moreover, our possibilities in this world demarcate our phenom-
enal field and define our most basic existential feelings. For instance, a
phenomenal field in which I cannot perform, an I-Can-Not kind of field,
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 flexible
boundary, we cannot perform. When things go wrong—particularly in
the case of life-threatening events—our boundaries narrow and our prac-
tical field 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 field. 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 field 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 dis-
tinction 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 conspicu-
ous.” Instead, “body and world are, to some extent at least, undifferenti-
ated” (p. 95, my emphasis). Thus, “without a firm boundary between
internally and externally directed senses, it is not possible to cleanly sep-
arate 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 finding oneself in-the-world” (Ratcliffe, 2015, p. 35).
Furthermore, alterations in mood reflect the sense of how we feel within
the world. Indeed, when our mood changes, we experience the world dif-
ferently (Jaspers, 1963). For instance, when we are in a depressed mood,
our range of possibilities decreases and the pragmatic phenomenal field
representing the I-can shrinks, resulting in a feeling that almost anything
is beyond our abilities: The phenomenal field becomes an I-Can-Not kind
of field, and over time, we may become isolated from the world (Ratcliffe,
2015). Likewise, when one is sick, “the body that previously opened up
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 finding oneself in-the-world, they can be
described in terms of body-schema precisely because the phenomenolog-
ically 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
modifications at the body-schema level; therefore, any changes in mood
may be reflected 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 “feel-
ings 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 bod-
ily 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 conspicu-
ous body is not just something that withdraws from a within-world activ-
ity; 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 flexibility 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 & Littlefield 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 phe-
nomenological perspective. Current Opinion in Psychiatry, 22(6), 570–575.
https://doi.org/10.1097/yco.0b013e3283318e5c.
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.
Heidegger, M. (1996). Being and time (J. Stambaugh, Trans.). Albany: New
York Press.
Jaspers, K. (1963). General psychopathology. 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.
Merleau-Ponty, M. (2002). Phenomenology of perception (C. Smith, Trans.).

O’Regan, K. J. (2010). Explaining what people say about sensory qualia. In N.
Gangopadhyay, M. Madary, & F. Spicer (Eds.), Perception, action, and con-
sciousness (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
O’Shaughnessy, B. (2000). Consciousness and the world. Oxford: Clarendon
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 sim-
ply ours, or are they us?” (p. 291)—James (1890) suggests that owner-
ship 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 know-
ing that this is my body and feeling that this is my body can be defined in
terms of the difference between ownership (knowing) and sense of own-
ership (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 vari-
ous sources—for instance, matching between proprioception and visual
feedback. Indeed, different kinds of bodily information must be syn-
chronized to achieve a sense of ownership. As long as no conflicts ensue,

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 flow of bodily experiences” (Synofzik, Vosgerau, & Newen,
2008, p. 420). Yet, the onset of conflicts 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 “experi-
ence our body parts as strange, peculiar or alien” (Synofzik et al., 2008,
p. 420).
SBO does not necessitate reflection of any kind but rather is part
of the pre-reflective 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 first-
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 identifiable sense of owner-
ship. 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
difficulty 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 rea-
son 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 fitted 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 expe-
rience 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 syn-
chronization between two different sources of information: visual and
tactile (Tsakiris & Haggard, 2005).
This experiment demonstrates that SBO is not influenced 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 bod-
ily 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… some-
thing 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 pros-
thetic 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/fixed model from the outset. Based on the LTBM, we
know that the hand should be explicitly situated in the phenomenal field.
3 OWNERSHIP 33
Therefore, while an SBO is not strongly projected onto a tool, the rubber
hand fits 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, bot-
tom-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 experien-
tially transparent. For this to occur, the limb must become fixed within
the LTBM, precisely because the LTBM provides a sense of transparency
at the body-schema level. In other words, unless a prosthesis fits naturally
into the LTBM, it will never become transparent and consequently can-
not 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 exam-
ples from Murray’s (2004) study of individuals fitted with prostheses.
Murray asked his interviewees the following questions: “How much do
you actually notice your artificial 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 pros-
thesis. 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 com-
pletely failed to develop a sense of ownership or an SA toward his pros-
thesis. 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 aware-
ness 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 own-
ership can change over time. This provides support for the argument that
sense of ownership is flexible 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 floor, 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,
The nuances in this testimony are significant. 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 flexible. 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 owner-
ship 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 experienc-
ing it as MINE. Indeed, JGY states: “it is not actually part of my body’s
flesh, 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 tech-
nology, 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
Transparency
Mine but not Me
Not Me and not Mine

Sense of body-ownership
- - -
Fig. 3.1 Three levels of the sense of body-ownership. We can define three lev-
els 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 flexibility,
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 crit-
ical 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 findings 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 defined as autoscopic. During
such experiences, both sense of embodiment and SBO alter. In addi-
tion, subjects with psychiatric conditions such as schizophrenia, depres-
sion, anxiety, and dissociative disorders sometimes report these kinds of
experiences. In general, there are three kinds or levels of autoscopic expe-
riences: 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 figure shows the

phenomenology of autoscopic experiences as well as the brain mechanisms associ-
ated with this phenomenology. (Illustration taken from Lopez, Halje, & Blanke,
(2008): https://shamelesslyatheist.files.wordpress.com/2009/11/autoscopy.jpg)
38 Y. ATARIA
representative example of this kind of experience: “It wasn’t hard to real-

ize 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 figure sometimes acts like a reflection 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 dou-
ble” (Brugger, Regard, & Landis, 1997, p. 22). The following testimony
exemplifies 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 difficult 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 gen-
erally 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 physi-
cal body and somewhat elevated” (Blanke et al., 2008, p. 430). Others
suggest that OBE can be defined as a kind of disembodiment: “the expe-
rience that the subject of conscious experience is localized outside the
person’s bodily borders” (Blanke & Metzinger, 2008, p. 9). The follow-
ing 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 floating 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 misidentification syndrome in which one fails to
recognize oneself in the mirror, even mistakenly treating the reflection 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 reflected 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 find it bizarre to see a
5 Indeed, a fundamental question, to which we have found no satisfactory answer in the
scientific literature, is whether these subjects felt within their body. There are, however,
some possible hints. Given the considerable overlap between delusional misidentification
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 misidentification syndrome also have
deficits 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 recog-

nize himself in the mirror, he even tried to shake the hand of the figure
he saw in the mirror.
We can now reformulate the question more accurately: Should an OBE
be defined 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 defined 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 figure would answer that it does
not know—similarly to Maupassant’s answer when he encountered his
reflection in the mirror. In fact, even if the illusory figure were asked
directly, “is this so-called physical body yours?”, the figure 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 findings from
pathological cases indicate that this kind of answer is possible. For
instance, Ramachandran gives the following example:
Arthur sometimes duplicated himself! The first 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 figure were to reply, “I am not sure, but this
physical body feels somewhat familiar,” or “it does not merely look famil-
iar but feels familiar,” this would necessitate a complete reconsideration
of what it means to undergo a full OBE. Namely, should we define 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 famil-
iar 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 refor-
mulate the concept of an out-of-body-experience by redefining this phe-
nomenon 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 local-
ized 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) identification 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
first-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, describ-
ing themselves as ‘pure consciousness’” (Alvarado, 2000, p. 186). However, beyond the
obvious fact that these descriptions are extremely vague, it seems that from the phenom-
enological 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 defined as autoscopic phenomena. However,
if these individuals experience an autoscopic phenomenon, it should be defined 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 influence of this
drug one can develop very strong OBEs. However, I was unable to find sufficient evidence
of this in scientific 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 defining 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 dis-
tinct neural substrates that are, respectively, located in the premotor cor-
tex and the temporoparietal junction. Thus, according to Serino et al.
(2013), “clinical evidence and new research conducted on the RHI sup-
port 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 exper-
iment 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, facilitat-
ing 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 defined as a sense of
disownership toward that biological body. Note, however, that whereas
Ehrsson’s group defines body-disownership as lack of SBO, in this book
the definition 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 read-
ing 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 suffi-
cient to prevent the full body-ownership illusion.” In practice, the “first
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 experi-
ments, 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 defined 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 bio-
logical body. Ehrsson’s studies apply techniques used in the case of RHI
toward the whole body. In these studies, the virtual figure 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 figure 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 environ-
ment. 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 impor-
tance. 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 expe-
riences (e.g., autoscopic hallucination, heautoscopy, and OBE), all of
which share at least one feature: a decline in SBO. More precisely, dep-
ersonalization and autoscopic experiences are located on the same spec-
trum. 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,
In this context, we can now begin examining situations in which indi-

viduals 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)-expe-
rience. The separation in such a case is so radical that the individual’s
SBO totally collapses. At this point of extreme and fundamental impair-
ments 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 deperson-
alization might be more subtle, functionally based, less neurologically damaged versions
of well-known parietal lobe neurological syndromes such as neglect, finger agnosia, and
hemidepersonalization” (Simeon et al., 2000, p. 1786). In turn, the findings 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 expe-

rience. 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 defined “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 figure in the mir-
ror 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, impos-
sible, 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
infinitum.
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 reflected
image are always synchronized: “My body in the mirror never stops fol-
lowing 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 our-
selves and our mirror image remains partial. Indeed, we can never adopt
the point of view of the reflected image. With the exception of some
severe psychiatric cases,15 the figure 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 figure
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
reflected 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 fill this
void by recourse to the image in the mirror, it refers me back to an origi-
nal 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-identification
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 individ-
ual retains the dual structure of being simultaneously subject and object.
Indeed, an OBE is simply a strengthened version of this inherent struc-
ture. In contrast, negative heautoscopy, a condition in which the indi-
vidual 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 experi-
ence negative heautoscopy are not influenced 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 heautos-
copy (Figs. 3.3 and 3.4).
48 Y. ATARIA
Experience of unreal world (partial

detachment)
B OBE
Everyday
experience
Depersonalization
C
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 simplified

(though not necessarily linear, as in this representation) presentation of the rela-
tionship 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 finally 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 finally 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 field, 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 defined 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 artificial. Indeed, in
our daily lives these cognitive mechanisms go hand in hand. The next
chapter describes the complex relationship between the SBO and SA.
References
Alvarado, C. S. (2000). Out-of-body experiences. In E. E. Cardeña, S. J. Lynn,
& S. E. Krippner (Eds.), Varieties of anomalous experience: Examining the
scientific evidence (pp. 183–218). Washington, DC: American Psychological
Associatio.
American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Blanke, O., Arzy, S., & Landis, T. (2008). Illusory perceptions of the human
body and self. In G. Goldenberg & B. Miller (Eds.), Handbook of clinical neu-
rology. Neuropsychology and behavioral neurology (Vol. 88, pp. 429–458).
50 Y. ATARIA
Blanke, O., Landis, T., Spinelli, L., & Seeck, M. (2004). Out-of-body experience
and autoscopy of neurological origin. Brain, 127(2), 243–258. https://doi.
org/10.1093/brain/awh040.
Blanke, O., & Metzinger, T. (2008). Full-body illusions and minimal phe-
nomenal selfhood. Trends in Cognitive Sciences, 13(1), 7–13. https://doi.
org/10.1016/j.tics.2008.10.003.
Blanke, O., & Mohr, C. (2005). Out-of-body experience, heautoscopy,
and autoscopic hallucination of neurological origin implications for neu-
rocognitive mechanisms of corporeal awareness and self consciousness.
Brain Research Reviews, 50(1), 184–199. https://doi.org/10.1016/j.
brainresrev.2005.05.008.
Botvinick, M., & Cohen, J. (1998). Rubber hand “feel” touch that eyes see.
Nature, 391, 756.
Brugger, P., Regard, M., & Landis, T. (1997). Illusory reduplication of one’s
own body: Phenomenology and classification of autoscopic phenom-
ena. Cognitive Neuropsychiatry, 2(1), 19–38. https://doi.org/10.1080/
135468097396397.
Curran, H. V., & Morgan, C. (2000). Cognitive, dissociative and psychoto-
genic effects of ketamine in recreational users on the night of drug use
and 3 days later. Addiction, 95(4), 575–590. https://doi.org/10.1046/
j.1360-0443.2000.9545759.x.
De Preester, H., & Tsakiris, M. (2009). Body-extension versus body-incorpo-
ration: Is there a need for a body-model? Phenomenology and the Cognitive
Sciences, 8(3), 307–319.
de Vignemont, F. (2007). Habeas corpus: The sense of ownership of
org/10.1111/j.1468-0017.2007.00315.x.
Debruyne, H., Portzky, M., Peremans, K. P., & Audenaert, K. (2011). Cotard’s
syndrome. Mind & Brain, the Journal of Psychiatry, 2(1), 67–72.
Dieguez, S. (2013). Doubles everywhere: Literary contributions to the study of
the bodily self. In J. Bogousslavsky & S. Dieguez (Eds.), Literary medicine:
Brain disease and doctors in novels, theater, and film (Vol. 31, pp. 77–115).
Basel: Karger Publishers. https://doi.org/10.1159/000345912.
Dieguez, S., & Lopez, C. (2017). The bodily self: Insights from clinical and
experimental research. Annals of Physical and Rehabilitation Medicine, 60(3),
198–207. https://doi.org/10.1016/j.rehab.2016.04.007.
Fleminger, S., & Burns, A. (1993). The delusional misidentification syndromes
in patients with and without evidence of organic cerebral disorder: A struc-
tured review of case reports. Biological Psychiatry, 1, 22–32. https://doi.
org/10.1016/0006-3223(93)90274-h.
3 OWNERSHIP 51
Fuchs, T. (2005). Corporealized and disembodied minds: A phenomenological

view of the body in melancholia and schizophrenia. Philosophy, Psychiatry, &
Psychology, 12(2), 95–107.
Press.
Gallagher, S. (2017). Enactivist interventions: Rethinking the mind. New York:
Oxford University Press.
Guterstam, A., & Ehrsson, H. H. (2012). Disowning one’s seen real body dur-
ing an out-of-body illusion. Consciousness and Cognition, 21(2), 1037–1042.
https://doi.org/10.1016/j.concog.2012.01.018.
James, W. (1890). The principles of psychology (Vol. 1). London: Macmillan.
Kimura, B. (1994). Psychopathologie der Zufaelligkeit oder Verlust des
Aufenthaltsortes beim Schizophrenen. Daseinsanalyse, 11, 192–204.
Kokkinara, E., Kilteni, K., Blom, K. J., & Slater, M. (2016). First person per-
spective of seated participants over a walking virtual body leads to illusory
agency over the walking. Scientific Reports, 6(28879), 1–11. https://doi.
org/10.1038/srep28879.
Legrand, D. (2006). The bodily self: The sensori-motor roots of pre-reflective
self-consciousness. Phenomenology and the Cognitive Sciences, 5(1), 89–118.
Legrand, D. (2007). Pre-reflective self-consciousness: On being bodily in the
world. Janus Head, 9(2), 493–519.
Lopez, C., Halje, P., & Blanke, O. (2008). Body ownership and embodiment:
Vestibular and multisensory mechanisms. Clinical Neurophysiology, 38(3),
149–161. https://doi.org/10.1016/j.neucli.2007.12.006.
Maravita, A., Spence, C., & Driver, J. (2003). Multisensory integration and the
body schema: Close to hand and within reach. Current Biology, 13, 531–539.
Maselli, A., & Slater, M. (2013). The building blocks of the full body owner-
ship illusion. Frontiers in Human Neuroscience, 7(83), 1–15. https://doi.
org/10.3389/fnhum.2013.00083.
Morgan, H. L., Turner, D. C., Corlett, P. R., Absalom, A. R., Adapa, R., Arana,
F. S., … Fletcher, P. C. (2011). Exploring the impact of ketamine on the
experience of illusory body ownership. Biological Psychiatry, 69(1), 35–41.
https://doi.org/10.1016/j.biopsych.2010.07.032.
Moseley, L., Olthof, N., Venema, A., Don, S., Wijers, M., Gallace, A., & Spence,
C. (2008). Psychologically induced cooling of a specific body part caused by
the illusory ownership of an artificial counterpart. Proceedings of the National
Academy of Sciences of the USA, 35(5), 13169–13173.
Murray, C. (2004). An interpretative phenomenological analysis of the embod-
iment of artificial limbs. Disability and Rehabilitation, 26(16), 963–973.
https://doi.org/10.1080/09638280410001696764.
52 Y. ATARIA
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.
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.
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 defined 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 hap-
pen” (Gallagher, 2007, p. 347, my emphasis). Whereas SA is usu-
ally described “as first-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 define 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

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 pro-
cesses 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 fingers. Rather, something in us, not even words but
merely abstract thoughts, struggles to find its way out through our
fingers. However, if we attempt to type the same sentence using the
DVORAK Simplified Keyboard rather than the QWERTY keyboard,
we would find ourselves struggling with our own fingers because they
would no longer function on automatic pilot. This “struggle” repre-
sents a explicit sense of control, while our fingers 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-reflective 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 gener-
ate this pre-reflective SA. In fact, as in the case of the sense of body-own-
ership (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 cog-
nitive 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 the-
oretical 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 fun-
damental mistake. Indeed, even though the SA can be extended to
external tools, “participants reported significantly 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), sen-
sorimotor cortex, extrastriate body area (EBA), and insula (Arzy, Thut, Mohr, Michel, &
Blanke, 2006; Blanke, 2012; Tsakiris, Hesse, Boy, Haggard, & Fink, 2006). The process-
ing of interoceptive information occurs on well-defined pathways from the dorsal root of
spinal nerves to the thalamus, nucleus of the solitary tract. This is then relayed to the cen-
tral cortical processing regions of the anterior cingulate cortex (ACC) and insular cortex
(Craig, 2003; Critchley & Harrison, 2013). Essentially, although neural processing con-
nected 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 “gen-
eral 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.
Scientific literature sometimes confuses anarchic hand syndrome
with alien hand syndrome, defining 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 defined 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 for-
eign limb. In the context of this book, it is significant that those report-
ing 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 syn-
drome. In the case of anarchic hand syndrome, individuals lose the abil-
ity 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
slap the errant hand with the so-called “good” hand. These subjects
tend to deny that a psychiatric disorder is responsible for the distur-
bance. In fact, while some are unaware of their involuntary goal-di-
rected 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). Specifically, even if they deny having any
kind of problem, analysis of their movements reveals they are never-
theless unconsciously aware of it (Biran, Giovannetti, Buxbaum, &
Chatterjee, 2006).
In extreme cases, patients with anarchic hand syndrome have woken
up to find 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 pre-
sented initially with mild right-sided weakness and naming difficulties.
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 func-
tion 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, trans-
lated 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 conflict 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 defined in scientific literature as forms of dis-
ownership (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 defined 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,
first 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
4.3.1 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 paraly-
sis, 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 deficit) 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 specificity 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, dam-
age is detected at the proprioceptive level. These findings lead Vallar
and Ronchi (2009) to suggest that the phenomenon represents body-
schema deficits. However, delusional disownership can extend to acces-
sory objects associated with the affected limb, such as a wedding ring,
apparently indicating that sensorimotor deficits alone cannot explain
body-disownership. Some even suggest that “somatoparaphrenia is not
simply a consequence of primary sensorimotor deficits, but a specific
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 ques-
tions 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 defined 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 symp-
toms 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 first 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 influenced 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 mecha-
nism 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 rep-
resent GA’s interpretation of loss of ownership or alternatively his inter-
pretations of some other basic cognitive injury or even a combination of
deficits 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 ano-
sognosia, 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 cogni-
tive terms, AC’s frustration results from deficits at the SA level.
AC’s experience can improve our understanding of the phenom-
enological 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,
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
Scientific literature does not define 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 experi-
ence 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, com-
bined 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 disown-
ership 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 combi-
nation 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, somatoparaphre-
nia 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 finds it unbearable to live with the disowned limb. Thus, in
the words of GH—a 41-year-old man who developed somatoparaphre-
nia following a right temporoparietal stroke—it is impossible to ignore
4 What Guterstam and Ehrsson define (2012) as body-disownership (see the detailed dis-
cussion in Chapter 3) is in fact the lack of sense of body-ownership.

62 Y. ATARIA
the disowned limb: “It was very difficult 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 dis-
ownership. 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 unbear-
able paradox may develop: I cannot control my own hand under any cir-
cumstances, 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 sug-
gest that at least on some level, somatoparaphrenia is “the patient’s inter-
pretation 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 accom-
panied by a strong sense of delusional belief. Moreover, recent findings
(Romano, Gandola, Bottini, & Maravita, 2014) reveal that patients expe-
riencing somatoparaphrenia do not demonstrate physical arousal when
their non-belonging [left] arm is under threat. Furthermore, at least in
this study, patients suffering from anosognosia for somatosensory defi-

cit 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 miso-
plegia 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 dis-
pose 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 expe-
rienced an episode of acute loss of consciousness following a spontane-
ous 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 fingers 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) find it interesting “that anosognosia and

misoplegia coexisted in one patient,” further arguing that “this is sur-
prising given that they reflect 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 exemplifies Moss and Turnbull’s observation (1996) that “ano-
sognosia 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, sub-
jects 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 (theo-
retical 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 impair-
ment that initially prompts the delusional belief and (b) the presence of a second neu-
ropsychological 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.
4.3.1.3 Somatoparaphrenia: A Full-Blown Conflict

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
signifies deficits 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 pres-
ence of the SBO, which remains partially intact. Apparently, body-
disownership can develop over and above the SBO. In fact, disowner-
ship can be defined 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 conflict 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, somato-
paraphrenia leaves the feeling of ownership intact while damaging the
feeling of agency. This first-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 conflict
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 conflict on at the body-image level between judgment of agency
and judgment of ownership. In this way, the basic conflict between feel-
ing of agency and judgment of agency can escalate into a full-blown con-
flict 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 judg-
ment 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 identified and described BIID in terms of Psychopathia
Sexualis—sexual attraction to amputees or others with disabilities (Wakefield, Frank, &

Meyers, 1977). However, more recent findings argue strongly against this thesis (Furth &
Smith, 2000). Based on pre/postoperative evaluations, scholars have argued that individu-
als 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 amputa-
tion 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
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 configuration 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 fun-
damental 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 “phe-
nomenology of BIID cannot be considered delusional given that individuals
with BIID do not harbor any false beliefs or cognitions about external real-
ity 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 significantly
improved quality of life after amputation, concurring with First’s conclu-
sion (2005): In most cases, the amputation is motivated by a feeling that
only becoming an amputee can restore the true self or identity. More
specifically, First finds that those (six) “subjects who had an amputation
at their desired site reported that following the amputation they felt bet-
ter 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 identified 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 pri-
mary 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 seri-
ous 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 per-
form 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 sit-
uated 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 define BIID in terms of disownership, then disown-
ership can almost inevitably be generated even when the SA remains
intact. Thus, disownership results neither from a lack of sense of owner-
ship nor from a lack of SA but rather from a basic clash between the feel-
ing of ownership and the feeling of agency at the body-schema level. Yet,
as we will see, although this conflict is necessary it is insufficient 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 finally
(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—for-
eign 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
with phantom limb sensations who has the feeling that his miss-
ing limb is still a part of his body while acknowledging the real-
ity 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 real-
ity that it is in fact a part of them. While phantom sensations can be
described as “animation without incarnation,” we can define 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 phys-
ically 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 offline 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
fixed within the LTBM. As we previously saw, the sense of transpar-
ency 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-ob-
ject 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 the-
sis 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 conflict between the dif-
ferent levels on which we experience our body. In turn, this contradic-
tion 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 specific 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 representa-
tion 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 first-order contradiction at the level
of body-schema between feeling of ownership and feeling of agency is
not sufficient to generate such a feeling. A second-order contradiction is
likewise necessary.
4.3.2.2 Body-Ownership Versus Body-Disownership

First finds (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.
Keeping this in mind, we now can ask: How can an individual simul-
taneously 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), impair-
ments 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 feel-
ing 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 deficiencies in the SBO.
Under such circumstances, individuals seek the best explanation for the
current situation by means of high-level interpretative cognitive pro-
cesses. 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 own-
ership 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 devel-
oping 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 conflict 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 mis-
match 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 accessi-
ble to (naïve kind of) introspection, rather than on their feeling of own-
ership. 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 own-
ership 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 knowl-
edge (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.
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
conflict 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 some-
how 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 phe-
nomenon, 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 first and
foremost an outcome of an inherent conflict within the body-schema:
Whereas the feeling of ownership is lacking, the feeling of agency
remains intact. This first-order conflict may in turn lead to a second-
order clash between body-schema and body-image. This twofold conflict
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 perspec-
tive 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-sub-
ject). As a result, an intolerable conflict 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

Scientific literature (de Vignemont, 2010) defines somatoparaphre-
nia and BIID as types of disownership. Based on this definition, 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 first-order contradiction between feeling of ownership and feel-
ing of agency at the body-schema level, the second-order contradic-
tion 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 reflection), 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 essen-
tially, “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 findings it seems at least possible to sug-
gest that there is a fundamental gap between 1pp and 3pp, that is it to say that experiencing
one’s body from a first 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.
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 out-
come can be body-disownership.
Ownership Agency
Body-Schema Feeling of Feeling of
ownership agency
Second order contradiction First order contradiction
Body-Image Judgment of Judgment of

ownership agency
References
Arzy, S., Thut, G., Mohr, C., Michel, C. M., & Blanke, O. (2006). Neural basis
of embodiment: Distinct contributions of temporoparietal junction and extra-
striate body area. Journal of Neuroscience, 26(31), 8074–8081.
Banks, G., Short, P., Martínez, A. J., Latchaw, R., Ratcliff, G., & Boller, F.
(1989). The alien hand syndrome. Clinical and postmortem findings. Archives
of Neurology, 46(4), 456–459.
Biran, I., Giovannetti, T., Buxbaum, L., & Chatterjee, A. (2006). The alien hand
syndrome: What makes the alien hand alien? Cognitive Neuropsychology, 23(4),
563–582. https://doi.org/10.1080/02643290500180282.
Blanke, O. (2012). Multisensory brain mechanisms of bodily self-consciousness.
Nature Reviews Neuroscience, 13(8), 556–571.
Blanke, O., Morgenthaler, F. D., Brugger, P., & Overney, L. S. (2009).
Preliminary evidence for a fronto‐parietal dysfunction in able‐bodied partic-
ipants with a desire for limb amputation. Journal of Neuropsychology, 3(2),
181–200. https://doi.org/10.1348/174866408x318653.
Bogen, J. E. (1993). The callosal syndromes. In K. M. Heilman & E. Valenstein
(Eds.), Clinical neuropsychology (3rd ed., pp. 337–407). New York: Oxford
University Press.
Brion, S., & Jedynak, C. P. (1972). Troubles du transfert interhemispherique.
A propos de trois observations de tumeurs du corps calleux. Le signe de la
main. Revue Neurologique, 126(4), 257–266.
Brugger, P., Lenggenhager, B., & Giummarra, M. J. (2013). Xenomelia: A social
neuroscience view of altered bodily self-consciousness. Frontiers in Psychology,
4(204), 1–7. https://doi.org/10.3389/fpsyg.2013.00204.
76 Y. ATARIA
Cogliano, R., Crisci, C., Conson, M., Grossi, D., & Trojano, L. (2012). Chronic
somatoparaphrenia: A follow-up study on two clinical cases. Cortex, 48(6),
758–767. https://doi.org/10.1016/j.cortex.2011.08.008.
Coltheart, M. (2010). The neuropsychology of delusions. Annals of the New
York Academy of Sciences, 1191(1), 16–26.
Craig, A. D. (2003). Interoception: The sense of the physiological condition of
the body. Current Opinion in Neurobiology, 13(4), 500–505.
Critchley, H. D., & Harrison, N. A. (2013). Visceral influences on brain and
behavior. Neuron, 77(4), 624–638.
Critchley, M. (1953). The parietal lobe. New York: Hafner Press.
Critchley, M. (1973). Misoplegia or hatred of hemiplegia. Mount Sinai Journal
of Medicine, 41(1), 82–87.
Davies, M., Coltheart, M., Langdon, R., & Breen, N. (2002). Monothematic
delusions: Towards a two-factor account. Philosophy, Psychiatry and Psychology,
8(2–3), 133–158. https://doi.org/10.1353/ppp.2001.0007.
de Saint-Exupéry, A. (1971). The little prince (K. Woods, Trans.).
Harmondsworth: Penguin Books.
Della Sala, S., Marchetti, C., & Spinnler, H. (1994). The anarchic hand: A fron-
tomesial sign. In F. Boller & J. Grafman (Eds.), Handbook of neuropsychology
(Vol. IX, pp. 233–255). Amsterdam: Elsevier.
Farrer, C., Franck, N., Georgieff, N., Frith, C., Decety, J., & Jeanneroda, M.
(2003). Modulating the experience of agency: A positron emission tomogra-
phy study. NeuroImage, 18, 324–333.
Feinberg, T. E., Venneri, A., Simone, A. M., Fan, Y., & Northoff, G. (2010).
The neuroanatomy of asomatognosia and somatoparaphrenia. Journal
of Neurology, Neurosurgery & Psychiatry, 81(3), 276–281. https://doi.
org/10.1136/jnnp.2009.188946.
First, M. B., & Fisher, C. E. (2011). Body integrity identity disorder: The per-
sistent desire to acquire a physical disability. Psychopathology, 45(1), 3–14.
https://doi.org/10.1159/000330503.
Fisher, K., & Smith, R. (2000). More work is needed to explain why patients
ask for amputation of healthy limbs. BMJ, 320(7242), 1147. http://dx.doi.
org/10.1136/bmj.320.7242.1147/a.
Fotopoulou, A., Jenkinson, P. M., Tsakiris, M., Haggard, P., Rudd, A., & Kopelman,
M. D. (2011). Mirror-view reverses somatoparaphrenia: Dissociation between
first-and third-person perspectives on body ownership. Neuropsychologia, 49(14),
3946–3955. https://doi.org/10.1016/j.neuropsychologia.2011.10.011.
Frith, C. D., Blakemore, S. J., & Wolpert, D. M. (2000). Abnormalities in the

awareness and control of action. Philosophical Transactions of the Royal Society
of London. Series B: Biological Sciences, 355(1404), 1771–1788.
Furth, G., & Smith, R. (2000). Apotemnophia: Information, questions, answers,
and recommendations about self-demand amputation. Bloomington: 1st Books
Library.
Gallagher, S. (2000). Philosophical conceptions of the self: Implications for cog-
nitive science. Trends in Cognitive Sciences, 4(1), 14–21.
Gallagher, S. (2007). The natural philosophy of agency. Philosophy Compass, 2(2),
347–357. https://doi.org/10.1111/j.1747-9991.2007.00067.x.
Gallagher, S. (2011). Multiple aspects in the sense of agency. New Ideas in Psychology,
30(1), 15–31. https://doi.org/10.1016/j.newideapsych.2010.03.003.
Gallagher, S., & Zahavi, D. (2008). The phenomenological mind: An introduction
to philosophy of mind and cognitive science. London: Routledge.
Gerstmann, J. (1942). Problem of imperception of disease and of impaired body
territories with organic lesions: Relation to body scheme and its disorders.
Archives of Neurology and Psychiatry, 48(6), 890–913.
Giummarra, M. J., Bradshaw, J. L., Nicholls, M. E., Hilti, L. M., & Brugger,
P. (2011). Body integrity identity disorder: Deranged body processing, right
fronto-parietal dysfunction, and phenomenological experience of body incon-
gruity. Neuropsychology Review, 21(4), 320–333. https://doi.org/10.1007/
s11065-011-9184-8.
Halligan, P. W., Marshall, J. C., & Wade, D. T. (1995). Unilateral somatopara-
phrenia after right hemisphere stroke: A case description. Cortex, 31(1), 173–
182. https://doi.org/10.1016/s0010-9452(13)80115-3.
Hilti, L. M., & Brugger, P. (2010). Incarnation and animation: Physical ver-
sus representational deficits of body integrity. Experimental Brain Research,
204(3), 315–326. https://doi.org/10.1007/s00221-009-2043-7.
Hilti, L. M., Hanggi, J., Vitacco, D. A., Kraemer, B., Palla, A., Luechinger, R., …,
Brugger, P. (2013). The desire for healthy limb amputation: Structural brain
correlates and clinical features of xenomelia. Brain, 136(1), 318–329. https://
doi.org/10.1093/brain/aws316.
Kalckert, A., & Ehrsson, H. (2012). Moving a rubber hand that feels like
your own: A dissociation of ownership and agency. Frontiers in Human
Neuroscience, 6(40), 1–14. https://doi.org/10.3389/fnhum.2012.00040.
Kritikos, A., Breen, N., & Mattingley, J. B. (2005). Anarchic hand syndrome:
Bimanual coordination and sensitivity to irrelevant information in uni-
manual reaches. Cognitive Brain Research, 24(3), 634–647. https://doi.
org/10.1016/j.cogbrainres.2005.03.015.
78 Y. ATARIA
Leiguarda, R., Starkstein, S., & Berthier, M. (1989). Anterior callosal haemor-
rhage. A partial interhemispheric disconnection syndrome. Brain, 112, 1019–
1037. http://dx.doi.org/10.1093/brain/112.4.1019.
Lewis, J. S., Kersten, P., McCabe, C. S., McPherson, K. M., & Blake, D. R.
(2007). Body perception disturbance: A contribution to pain in complex
regional pain syndrome (CRPS). Pain, 133(1), 111–119.
Loetscher, T., Regard, M., & Brugger, P. (2006). Misoplegia: A review of the lit-
erature and a case without hemiplegia. Journal of Neurology, Neurosurgery &
Psychiatry, 77(9), 1099–1100. https://doi.org/10.1136/jnnp.2005.087163.
Mailis, A. (1996). Compulsive targeted self-injurious behaviour in humans
with neuropathic pain: A counterpart of animal autotomy? Four case
reports and literature review. Pain, 64(3), 569–578. https://doi.
org/10.1016/0304-3959(95)00173-5.
Marchetti, C., & Sala, S. D. (1998). Disentangling the alien and anar-
chic hand. Cognitive Neuropsychiatry, 3(3), 191–207. https://doi.
org/10.1080/135468098396143.
Moss, A. D., & Turnbull, O. H. (1996). Hatred of the hemiparetic limbs
(misoplegia) in a 10 year old child. Journal of Neurology, Neurosurgery, and
Psychiatry, 61(2), 210.
Pearce, J. M. (2007). Misoplegia. European Neurology, 57(1), 62–64. https://
doi.org/10.1159/000102172.
Rahmanovic, A., Barnier, A. J., Cox, R. E., Langdon, R., & Coltheart, M.
(2012). “That’s not my arm”: A hypnotic analogue of somatoparaphre-
nia. Cognitive Neuropsychiatry, 17(1), 36–63. https://doi.org/10.1186/
cc12494.
Romano, D., Gandola, M., Bottini, G., & Maravita, A. (2014). Arousal
responses to noxious stimuli in somatoparaphrenia and anosognosia: Clues
to body awareness. Brain, 137(4), 1–11. https://doi.org/10.1093/brain/
awu009.
Sato, A., & Yasuda, A. (2005). Illusion of sense of self-agency: Discrepancy between
the predicted and actual sensory consequences of actions modulates the sense of
self-agency, but not the sense of self-ownership. Cognition, 94(3), 241–255.
Sedda, A. (2011). Body integrity identity disorder: From a psychological to a
neurological syndrome. Neuropsychology Review, 21(4), 334–336. https://doi.
org/10.1007/s11065-011-9186-6.
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., Hesse, M. D., Boy, C., Haggard, P., & Fink, G. R. (2006). Neural
signatures of body ownership: A sensory network for bodily self-conscious-
ness. Cerebral Cortex, 17(10), 2235–2244.
Tsakiris, M., Longo, M., & Haggard, P. (2010). Having a body versus
moving your body: Neural signatures of agency and body-ownership.
Neuropsychologia, 48(9), 2740–2749.
533–551. https://doi.org/10.1007/s00221-008-1562-y.
Van der Kolk, B. A., Perry, C., & Herman, J. L. (1991). Childhood origins of
self-destructive behavior. American Journal of Psychiatry, 148(12), 1665–
1671. https://doi.org/10.1176/ajp.148.12.1665.
Wakefield, P. L., Frank, A., & Meyers, R. W. (1977). The hobbyist: A euphe-
mism for self-mutilation and fetishism.Bulletin of the Menninger Clinic, 41(6),
539.
CHAPTER 5
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 defined 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 dis-
sociation 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 dysfunc-
tion in these mechanisms” (2003b, p. 779).
From a phenomenological perspective, a dissociative experience
can be defined 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 ref-
erence 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).

https://doi.org/10.1057/978-1-349-95366-0_5
82 Y. ATARIA
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 fol-
lowing 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 con-
ducted by Ozer, Best, Lipsey, and Weiss (2008), in comparison with six
other risk factors—prior trauma, previous psychological adjustment, fam-
ily history of psychopathology, perception of a life-threatening situation
during the trauma, post-trauma social support, and peritraumatic emo-
tional 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 exempli-
fied by the testimony of I., a former prisoner of war (POW):
The world starts to be , distorted, like objects in space that lose their mean-
ing… 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 dis-
torted, 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-threaten-
ing 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 hap-
pen…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 flatness. 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 flexible defense mechanism, enabling subjects to sep-
arate themselves from an unbearable reality. Let us consider this notion
further by examining various testimonies provided by survivors of ter-
ror attacks.1 Z.O., for example, describes her experience in the follow-
ing 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-profit 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 sup-
ported by Psychology Beyond Borders (PBB). For more methodological issues see Appendix 1.
“I recognize it, the body, but not like I know it to be normally. It’s a func-
tional 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 differ-
ent 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 defined as a semi-dissociative
state. Although at first R.M. apparently retained at least a weak SBO,
over the course of the traumatic incident this weakened further; even-
tually, she felt that her body was merely an object to which she was not
attached: “It’s a kind of object… flesh… without ownership. There’s no own-
ership. 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 define helplessness as a feeling of being “powerless or
incompetent” or “deprived of strength or power; powerless; incapacitated.” In addition,
helplessness defines a situation that the individual finds “impossible to control.” None
of these definitions 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 dur-
ing 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 any-
thing. 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 (fight or flight) and those in which no such option
exists, as is exemplified 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.).
Interestingly, most post-traumatic individuals who managed to func-

tion 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 auto-
matic 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 com-
ing towards me. Like that. And I’m…shouting to them…”Rocket!” I’m try-
ing 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 chil-

dren, I calmed them down. I was so stressed but I functioned like I wasn’t
connected to there…like everything was fine 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, testifies 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 briefly to the cognitive mech-
anism responsible for the development of somatoparaphrenia as an
extreme case of anarchic hand syndrome. We can now define this mech-
anism 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, fifteen 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.
which occurs at a clear point in time and not over a prolonged period,
POWs undergo severe and ongoing trauma. Therefore, examining tes-
timonies 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 nec-
essarily “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 inan-
imate 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. testifies 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 rela-
tions between these independent yet closely connected mechanisms deter-
mine whether or not a victim will be able to function during trauma.
To be more specific, 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 reac-
tions 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 significant fac-
tor 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 infinity, the dissociative mechanism
becomes dysfunctional. To clarify this notion, let us return to the exam-
ple 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 some-
how 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. Scientific literature (Baldwin,
2013; Bracha, 2004; Kozlowska, Walker, McLean, & Carrive, 2015) defines this phe-
nomenon as collapse or flaccid immobility. Under severe stress, and when the threat is per-
ceived as impossible to handle, this tonic immobility (characterized by stillness, fixed eyes
and stomach tension with a pounding heart rate of 100 bpm, and fast shallow breathing)
turns into flaccid immobility or fainting, including an extraordinary drop in heart rate and
blood pressure. This state is characterized by flaccid immobility (floppiness) 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 defined 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 termi-
nation. On the one hand, muscle stiffening changes to flaccidity 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.
individual would probably also feel uncomfortable. In both these cases,

SA:SBO < 1.6 However, if one could have perfect control over a prosthe-
sis 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 equiva-
lent (SA:SBO ≈ 1), the individual can function. Yet if the SBO is not
sufficiently 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 first-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 demon-
strated 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 resist-
ance 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 gen-
eral 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 inflicted 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 finger-
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 possibil-
ities, 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 first blow
the prisoner understands that he is totally and absolutely helpless. As we
saw, helplessness causes the field of action to shrink. While being tor-
tured, the victim understands that no one in-the-world will come to his
rescue:
The first 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 hav-
ing possessed the hue of life; but upon the first 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 helpless-

ness. 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 first 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
defined here as “a subjective experience” is also influenced by the theoretical approach,
while the theoretical approach is influenced 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.
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-
fiable 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 sur-
face shields me against the external world. At the first blow, however, this
trust in-the-world breaks down. The other person, opposite whom I exist physi-
cally 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 first
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 indi-
vidual’s existential experience over the long term. The tortured individ-
ual 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 flesh was left on my bones, just enough for bitter-
ness – 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 specifically 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 floor. 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, lim-
ited 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 find descriptions of such experiences that are lack-
ing in pathos. Shalamov’s book is an exception that provides an exact and in-depth description.
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 individ-
ual 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 flesh 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 trans-
formation of the person into flesh 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 situa-
tion 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 experi-
enced 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.
Consequently, the SA:SBO ratio now approaches infinity. 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
filth, 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 for-
eignness in-the-world that cannot be compensated by any sort of subse-
quent 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 inflict suffering and to destroy. (p. 39, my
emphasis)
Améry’s suicide is not an accident but rather, a result of a deep sense of hos-
tility toward his own body—as Schilder (1935) stresses: “When the whole
body is filled 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-injur-
ing behavior.
References
Ataria, Y. (2010). Consciousness-body-time: How do people think lacking their body?
(MA thesis, The Hebrew University of Jerusalem).
Ataria, Y. (2015a). Dissociation during trauma: The ownership-agency tradeoff
model. Phenomenology and the Cognitive Sciences, 14(4), 1037–1053. https://
doi.org/10.1007/s11097-014-9392-9.
Ataria, Y. (2015b). Sense of ownership and sense of agency during trauma.
Phenomenology and the Cognitive Sciences, 14(1), 199–212. https://doi.
org/10.1007/s11097-013-9334-y.
98 Y. ATARIA
Ataria, Y. (2015c). Trauma from an enactive perspective: The collapse of the

knowing-how structure. Adaptive Behavior, 23(3), 143–154. https://doi.
org/10.1177/1059712314578542.
Ataria, Y., & Neria, Y. (2013). Consciousness-body-time: How do people
think lacking their body? Humans Studies, 36(2), 159–178. https://doi.
org/10.1007/s10746-013-9263-3.
Baldwin, D. V. (2013). Primitive mechanisms of trauma response: An evolution-
ary perspective on trauma-related disorders. Neuroscience & Biobehavioral
Reviews, 37(8), 1549–1566.
Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity
of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735.
Bracha, S. H. (2004). Freeze, flight, fight, fright, faint: Adaptationist perspectives
on the acute stress response spectrum. CNS Spectrums, 9(9), 679–685.
London and New York: Rowman & Littlefield International.
Janet, P. (1889). L’automatisme psychologique. Paris: Alcan.
Janet, P. (1925). Psychological healing: A historical and clinical study (E. Paul &
C. Paul, Trans.). New York: Macmillan.
Kozlowska, K., Walker, P., McLean, L., & Carrive, P. (2015). Fear and
the defense cascade: Clinical implications and management. Harvard
Review of Psychiatry, 23(4), 263–287. https://doi.org/10.1097/
hrp.0000000000000065.
Leder, D. (1990). The absent body. Chicago: The University of Chicago press.
Marmar, C. R., Weiss, D., & Metzler, T. (1998). Peritraumatic dissociationand
posttraumatic stress disorder. In J. Bremner & C. Marmar (Eds.), Trauma, mem-
ory, and dissociation (pp. 229–252). Washington: American Psychiatric Press.
Marmar, C. R., Weiss, D. S., Schlenger, W. E., Fairbank, J. A., Jordan, B. K.,
Kulka, R. A., & Hough, R. L. (1994). Peritraumatic dissociation and post-
traumatic stress in male Vietnam theater veterans. The American Journal of
Psychiatry, 151(6), 902–907.
McNally, R. J. (2003a). Remembering trauma. Cambridge, MA: Belknap Press
of Harvard University Press.
McNally, R. J. (2003b). Psychological mechanisms in acute response to trauma.
Society of Biological Psychiatry, 53(9), 779–788. https://doi.org/10.1016/
s0006-3223(02)01663-3.
Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2008). Predictors of
posttraumatic stress disorder and symptoms in adults: A meta-analysis.
Psychological Trauma: Theory, Research, Practice, and Policy, S(1), 3–36.
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.
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 psy-
chic 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) defines deliberate self-injury as causing of intentional and
direct harm to body tissue without suicidal intent. However, not all
scholars accept this definition. The inability to provide an unequivocal
definition 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 mat-
ter 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 signifies
a deep-rooted difficulty in defining 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

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 testi-
mony 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 cru-
cial 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-mu-
tilation 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 findings 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 classified as deliberate self-harm” (Gratz, 2003,
p. 193). However, while in the short-term SIB reduces negative emo-
tions, 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 fol-
lowing 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
infinite 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,’” specifically
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 findings which indicate that those who engage in SIB usu-
ally 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 inflicted. 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 dam-
aging 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 defining SIB as intentional and direct injury to
one’s body tissue without suicidal intent, I prefer to use Herpertz’s (1995)
definition: 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 identifies the
body as the cause of suffering. We can thus argue that “both suicidal and
self-mutilating acts comprise deliberate physically self-injurious behav-
iors 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 stress-
ful 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 con-
trolling their anger, in addition to experiencing increased discomfort at
their angry feelings. These findings 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 flashbacks, 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 influencing
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 behav-
ior, enabling the individual to regulate feelings in various situations,
“as a result of the presence and interaction of earlier environmental and

genetic factors” (Nock, 2010, p. 351). Yet significantly, 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, how-
ever, 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 identifies a his-
tory 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, significant child-
hood 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 finding is both unsurprising and insuf-
ficiently specific. Indeed, Yates suggests (2009) that “specific forms
of maltreatment are differentially related to non-suicidal self-injury”
(p. 119). In particular, sexual abuse, neglect, emotional abuse, and phys-
ical abuse should not be addressed as the same phenomenon but rather
should be differentiated. However, as Gratz (2003) stresses, many stud-
ies 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 significant predictor of SIB.
Similarly, Gratz, Conrad, and Roemer (2002) contend that even after
controlling for other variables, sexual abuse remains a major predic-
tor 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, specific aspects of the experience that were associ-
ated 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 finds that physi-
cal 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) find that compared to childhood sexual and physical abuse, emo-
tional neglect is the strongest predictor for SIB. That being said, Gratz
(2003) argues that “there is some evidence that emotional neglect may
be a significant 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 child-
hood 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 defin-
ing 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 deficits in the structure of the traumatic memory as an auto-
biographical 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 eas-
ily removed. We thus suggest that whereas one kind of story—semantic
and explicit, yet poorly remembered—exists on the level of the autobio-
graphical 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
body-schema level. The subject remembers the sensory and emotional ele-
ments of the traumatic experience yet lacks the linguistic/contextual fac-
tor: “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 expe-
rienced as being without a context, and that is easily triggered by phys-
ically 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 flashbacks
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 disor-
der, 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 under-
stood 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 memo-
ries. 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 trau-
matic 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 pro-
longed 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 mem-
ories 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
sufficient pain to block out the inner pain and turmoil that was driving me
mad inside. A flood 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 con-
stant 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 testifies that she cut herself especially in those very private places
where the pain and the memory are the worst. A study among adult sur-
vivors of childhood sexual abuse reveals that vaginal lacerations are the
most common form of SIB (Weaver et al., 2004). According to Yates,
“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 spe-
cific locations. Jill cut herself in areas specifically 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 pro-
pose that Jill developed disownership toward a specific 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 abus-
ing 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 confirmation 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 somato-
paraphrenia, 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 deficits at the body-

schema level, located in a specific 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 child-
hood in the following manner:
Physical beatings, sexual intercourse, oral and anal sex were part of my every-
day 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 fist. Strangely, this brought a little bit of relief. After that I
began hurting myself in various ways. … When I was fifteen 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 understand-
ing… 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 chil-
dren, a little boy aged two, and a little girl aged four. The first 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 horrific
memories had been pushed into the dark recesses of my mind, but some-
how 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
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 first 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 expla-
nation 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 contra-
dictory personalities, each unconscious of the other. One is the appar-
ently normal personality (ANP), which has apparently moved on and
denies any connection to the traumatic memories. The other is the emo-
tional 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 unbeara-
ble 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 inabil-
ity 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 influence” (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 affec-
tive material cognitively via self-reflection 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 first 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
traumatic experience. Thus, the body is a direct mediator of the trau-

matic 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 con-
tinues to represent the old reality, the “old body” prior to the trauma. The
old metaphors become empty and meaningless and are unable to repre-
sent 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 sys-
tems of beliefs and the so-called new language which attempts to find a
way to represent the unexpected world of trauma. Indeed, posttraumatic
survivors find 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 autobi-
ographical 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 find 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 trau-
matized. 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 testified that they sur-
vived in order to tell the stories of those who perished. Thus, it is some-
what 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 expe-
rience. 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 pro-
longed trauma, SIB provides an opportunity to create a new language.
6.5.3 Breaking the Silence

“Our view of man will remain superficial so long as we fail to go back to
that origin, so long as we fail to find, 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 justifications (e.g., use of the
word “because”). Nevertheless, it is difficult to find phenomenological studies that exam-
ine self-injuring behavior. We therefore felt that compromise was necessary, at least on this
point.
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 emo-
tion regulation in the absence of adaptive integrative, symbolic and
reflective 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 nullified 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 find a way to create a new lan-
guage—a bodily kind of language:
Voice is silence, flesh 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 dis-
tinct. 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

prereflectively 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-inflicted, and when that second, col-
lateral pain emerges, it will articulate in blood or blisters the open defini-
tion 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 gener-
ated 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, fluid and scabby. A voice
sears itself or a moment, in flesh. 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 flesh 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 emerg-
ing from the mouth, the carnal sound, but push pulse curve expand contract;
they are the ripple of flesh 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 trau-
matic 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 bound-
ary 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).
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 pro-
cess… It seems to be about attention and focus. The violence I inflict 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 finds 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 accompa-
nied 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 fright-
ening (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 fol-
lowing 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 find 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, par-
ticularly 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
or displaying blood and flesh) 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-in-
jury 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 hap-
pening, 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 pro-
found 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 defined 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 experi-
ence 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 first? My
daddy or me? I’d rather get there first. 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 cut-
ting, 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).
• overwhelmed by • feels the pain

feelings • does not feel
the pain (2/3), • increases • dissociated
feelings • no feelings at all SIB Dissociaon Relief
scores high on • decreases • back to ground
(e.g., depersonalizaon)
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 dissoci-
ation, 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 subsec-
tion 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 exam-
ined 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 vic-

timizer’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 defined as being-in-hostile-world, mak-
ing 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 percep-
tual field” (Husserl, 1936/1970, p. 106). Hence, if the body-as-subject
becomes loaded with feelings of self-hatred, the perceptual field turns
against the self-hating individual, making the world unbearable because
“in my perceptual field I find myself” (p. 108). Clearly, nothing is more
difficult 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 first 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”
(ibid). Dillon (1998) defines 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,
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 polar-
ized 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 expe-
riencing 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 dis-
gust 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 specifically, under such
circumstances, individuals can loathe their body and even totally adopt
the victimizer’s perspective and ideology. Nonetheless, on the pre-
reflective 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 conflict 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
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 circum-
stances, 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 cog-
nitive coding, may cause significant 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 significant 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 expe-
riences the world through the body, the world becomes flooded 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 ena-
ble 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 engag-
ing 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 own-
ership 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 ena-
bles 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 dur-
ing 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.
References
Arnold, L. (1995). Women and self-injury: A survey of 76 women. Bristol: Bristol
Crisis Service for Women.
Ataria, Y. (2017). The structural trauma of western culture: Toward the end of
humanity. New York: Palgrave Macmillan.
Bennun, I. (1984). Psychological models of self-mutilation. Suicide and Life-
Threatening Behavior, 14(3), 166–186.
Boudewyn, A. C., & Liem, J. H. (1995). Childhood sexual abuse as a precur-
sor to depression and self-destructive behavior in adulthood. Journal of
Traumatic Stress, 8(3), 445–459. https://doi.org/10.1002/jts.2490080307.
Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of posttraumatic
stress disorder. Clinical Psychology Review, 23(3), 339–376.
Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002). Reasons for suicide
attempts and nonsuicidal self-injury in women with borderline personal-
ity disorder. Journal of Abnormal Psychology, 111(1), 198–202. https://doi.
org/10.1037/0021-843x.111.1.198.
de Vignemont, F. (2016). Pain and the spatial boundaries of the bodily self. Pain
and the conscious brain. International Association for the Study of Pain.
Dillon, M. C. (1998). Sartre on the phenomenal body and Merleau-Ponty’s
critique. In J. Stewart (Ed.), The debate between Sartre and Merleau-Ponty
(pp. 121–143). Evanston: Northwestern University Press.
Dubo, E. D., Zanarini, M. C., Lewis, R. E., & Williams, A. A. (1997).
Childhood antecedents of self-destructiveness in borderline personality
disorder. Canadian Journal of Psychiatry, 42(1), 63–69. https://doi.

org/10.1177/070674379704200110.
Dyer, K. F., Dorahy, M. J., Hamilton, G., Corry, M., Shannon, M., MacSherry,
A., … McElhill, B. (2009). Anger, aggression, and self‐harm in PTSD and
complex PTSD. Journal of Clinical Psychology, 65(10), 1099–1114. https://
doi.org/10.1002/jclp.20619.
Ehlers, A., & Clark, D. (2000). A cognitive model of posttraumatic stress disor-
der. Behaviour Research and Therapy, 38, 319–345.
Ehlers, A., Hackmann, A., & Michael, T. (2004). Intrusive re-experiencing in
post-traumatic stress disorder: Phenomenology, theory, and therapy. Memory,
12(4), 403–415.
Favazza, A. R. (1989). Why patients mutilate themselves. Psychiatric Services,
40(2), 137–145. https://doi.org/10.1176/ps.40.2.137.
Favazza, A. R. (1998). The coming of age of self-mutilation. Journal of Nervous
& Mental Diseased, 186(5), 259–268.
Favazza, A. R., & Conterio, K. (1988). The plight of chronic self-mutilators.
Community Mental Health Journal, 24(1), 22–30. https://doi.org/10.1007/
bf00755050.
Gratz, K. L. (2003). Risk factors for and functions of deliberate self-harm: An
empirical and conceptual review. Clinical Psychology: Science and Practice,
10(2), 192–205. https://doi.org/10.1093/clipsy.bpg022.
Gibbs, R. W. G. (2006). Embodiment and Cognitive Science. New York:
Cambridge University Press.
Gratz, K. L., Conrad, S. D., & Roemer, L. (2002). Risk factors for deliberate
self-harm among college students. American Journal of Orthopsychiatry,
72(1), 128–140.
Hawton, K., Rodham, K., Evans, E., & Weatherall, R. (2002). Deliberate
self harm in adolescents: Self report survey in schools in England. British
Medical Journal, 325(7374), 1207–1211. https://doi.org/10.1136/
bmj.325.7374.1207.
Herpertz, S. (1995). Self-injurious behaviour. Psychopathological and nosologi-
cal characteristics in subtypes of self-injurers. Acta Psychiatrica Scandinavica,
91(1), 57–68.
Husserl, E. (1936/1970). The crisis of European sciences and transcendental phe-
nomenology: And introduction to phenomenological philosophy (D. Carr, Trans.).
Evanston: Northwestern University Press.
Husserl, E. (1989). Ideas pertaining to a pure phenomenology and to a phenome-
nological philosophy—Second book: Studies in the phenomenology of constitution
(R. Rojcewicz & A. Schuwer, Trans.). Dordrecht: Kluwer.
Kemperman, I., Russ, M. J., & Shearin, E. (1997). Self-injurious behavior and
mood regulation in borderline patients. Journal of Personality Disorders,
11(2), 146–157. https://doi.org/10.1521/pedi.1997.11.2.146.
128 Y. ATARIA
Kim. (1993). Untitled. The Cutting Edge: A Newsletterfor Women Living with
Self-inflicted Vioknce, 4(3), 3–4.
Krans, J., Näring, G., Becker, E. S., & Holmes, E. (2009). Intrusive trauma
memory: A review and functional analysis. Applied Cognitive Psychology, 23(8),
1076–1088.
Lakoff, G., & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and
its challenge to western thought. New York: Basic Books.
Laub, D. (1995). Truth and testimony: The process and the struggle. In
C. Caruth (Ed.), Trauma: Explorations in memory (pp. 61–45). Baltimore,
MD: The Johns Hopkins University Press.
Laye-Gindhu, A., & Schonert-Reichl, K. A. (2005). Nonsuicidal self-harm
among community adolescents: Understanding the “whats” and “whys” of
self-harm. Journal of Youth and Adolescence, 34(5), 447–457. https://doi.
org/10.1007/s10964-005-7262-z.
Levi, P. (1959). If this is a man (S. Woolf, Trans.). New York: The Orion Press.
Levi, P. (1993). The drowned and the saved (R. Rosenthal, Trans.). London:
Abacus.
Linehan, M. (1993). Cognitive–behavioral treatment for borderline personality dis-
order. New York: Guilford Press.
Mazelis, R. (1998). The cutting edge. A Newsletter for Women Living with Self-
inflicted Violence, 9(3 [35]), 1–11.
McLane, J. (1996). The voice on the skin: Self‐mutilation and Merleau‐Ponty’s
theory of language. Hypatia: A Journal of Feminist Philosophy, 11(4),
107–118. https://doi.org/10.1111/j.1527-2001.1996.tb01038.x.
McNally, R. J. (2003). Remembering trauma. Cambridge, MA: Belknap Press of
Harvard University Press.
Merleau-Ponty, M. (1968). The visible and the invisible (C. Lefort, Ed., &
A. Lingis, Trans.). Evanston: Northwestern University Press.
Nock, M. K. (2008). Actions speak louder than words: An elaborated theo-
retical model of the social functions of self-injury and other harmful behav-
iors. Applied and Preventive Psychology, 12(4), 159–168. https://doi.
org/10.1016/j.appsy.2008.05.002.
Nock, M. K. (2010). Self-injury. The Annual Review of Clinical Psychology, 6,
339–369. https://doi.org/10.1146/annurev.clinpsy.121208.131258.
Nock, M. K., & Prinstein, M. J. (2005). Contextual features and behavioral func-
tions of self-mutilation among adolescents. Journal of Abnormal Psychology,
114(1), 140–146. https://doi.org/10.1037/0021-843x.114.1.140.
Ross, S., & Heath, N. L. (2003). Two models of adolescent self‐mutilation.
Suicide and Life-Threatening Behavior, 33(3), 277–287.
Sartre, J.-P. (1956). Being and nothingness (H. Barnes, Trans.). New York:
Philosophical Library.
Saxe, G. N., Chawla, N., & Van der Kolk, B. A. (2002). Self-destructive behavior
in patients with dissociative disorders. Suicide and Life-Threatening Behavior,
32(3), 313–320.
Stanley, B., Winchel, R., Molcho, A., Simeon, D., & Stanley, M. (1992).
Suicide and the self-harm continuum: Phenomenological and biochemical
evidence. International Review of Psychiatry, 4(2), 149–155. https://doi.
org/10.3109/09540269209066312.
Sutton, J. (2007). Healing the hurt within 3rd Edition: Understand self-injury
and self-harm, and heal the emotional wounds. Hachette UK.
Swannell, S., Martin, G., Page, A., Hasking, P., Hazell, P., Taylor, A., & Protani,
M. (2012). Child maltreatment, subsequent non-suicidal self-injury and the
mediating roles of dissociation, alexithymia and self-blame. Child Abuse &
Neglect, 36(7), 572–584. https://doi.org/10.1016/j.chiabu.2012.05.005.
Treat, J. W. (1995). Writing ground zero: Japanese literature and the atomic
bomb. Chicago: University of Chicago Press.
Umans, M. (1992). Untitled. The Cutting Edge: A Newsletter for Women Living
with Self-inflicted Violence, 3(3), 7.
Van der Kolk, B. A., & Fisler, R. (1995). Dissociation and the fragmentary
nature of traumatic memories: Overview and exploratory study. Journal
of Traumatic Stress, 8, 505–525. Retrieved January 11, 2011, from David
Baldwins Trauma Pages. http://www.trauma-pages.com/a/vanderk2.php.
self-destructive behavior. American Journal of Psychiatry, 148(12), 1665–1671.
https://doi.org/10.1176/ajp.148.12.1665.
science and human experience. Cambridge: MIT Press.
Weaver, T. L., Chard, K. M., Mechanic, M. B., & Etzel, J. C. (2004). Self-
injurious behaviors, PTSD arousal, and general health complaints within a
treatment-seeking sample of sexually abused women. Journal of Interpersonal
Violence, 19(5), 558–575. https://doi.org/10.1177/0886260504262965.
Yates, T. M. (2004). The developmental psychopathology of self-injurious behav-
ior: Compensatory regulation in posttraumatic adaptation. Clinical Psychology
Review, 24(1), 35–74. https://doi.org/10.1016/j.cpr.2003.10.001.
Yates, T. M. (2009). Developmental pathways from child maltreatment to non-
suicidal self-injury. In M. K. Nock (Ed.), Understanding nonsuicidal self-in-
jury: Origins, assessment, and treatment (pp. 117–137). Washington, DC:
American Psychological Association. https://doi.org/10.1037/11875-007.
CHAPTER 7
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 trau-
matic event via intrusive memories, flashbacks, 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 sufficient for PTSD to ensue.
Diagnostic criteria for PTSD (American Psychiatric Association, 2013)
include exposure to a traumatic event that meets specific stipulations and
the presentation of symptoms from each of four symptom clusters:
1. Re-experiencing, such as flashbacks.

2. Avoidance of memories, thoughts, feelings, or external reminders
of the event.

https://doi.org/10.1057/978-1-349-95366-0_7
132 Y. ATARIA
3. Negative cognitions and mood—for instance, a persistent and dis-

torted sense of blame of self or others, estrangement from others
or markedly diminished interest in activities, an inability to remem-
ber 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 defines a dissociative subtype

of PTSD. This modification is a result of various studies conducted
over the last 30 years that reveal a strong link between PTSD and dis-
sociation (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 significantly 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 symp-
toms (Carlson, Dalenberg, & McDade-Montez, 2012; Ginzburg, Butler,
Saltzman, & Koopman, 2010). Thus, based on a wide review of the rele-
vant literature, Lanius et al. (2010) argue that we can firmly 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 scientific literature, we suggest that (a)
chronic PTSD goes hand in hand with chronic symptoms of dissocia-
tion 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) defines
as trauma type II: “PTSD patients with prolonged traumatic experiences
such as chronic childhood abuse or combat trauma often show a clini-
cal 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 other-
wise specified 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
specified (DESNOS), includes the core symptoms of PTSD (re-experi-
encing, 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 difficulties; (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 sur-
vivors 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 situ-
ation, “the body is no longer a medium of experience and activity, an
opening onto a significant world filled 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 defined as a mood (Heidegger, 1996) or as exis-
tential 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 reflects bod-
ily 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… finally, the sick body may be experienced as that
which ‘stands in the way,’ an obstinate force interfering with our pro-
ject” (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
of transcending the body, she becomes completely identified with it”

(Fuchs, 2005, p. 100). Thus, the melancholic individual becomes totally
identified 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
field, 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 modifications. 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 find it impos-
sible 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) sug-
gests that the most significant 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 field is
transformed into an I-can-not kind of field because the body does not
allow us to act. Fuchs (2005) defines 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 field become an I-can-not
kind of field, but we begin to feel disabled, restricted, and immobilized,
as though external forces prevent us from acting in-the-world. The pro-
cess described here indicates that this sense of non-belonging is rooted
in some deficits 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 embed-
ded 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 find release
from that moment. In practice, this means that the traumatized indi-
vidual’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 imme-
diately 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 filled with trauma, the only
alternative is to embrace a 3PP toward the body. Under such circum-
stances, 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 ongo-
ing 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 survi-
vor 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
chapter seeks to pinpoint this notion, first 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 emo-
tional 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 dissoci-
ation. 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 discon-
nected from the traumatic event, to the point of not even remem-
bering 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 trau-
matic memories at bay, and the emotional personality (EP) fixed 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 defined 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 physi-
cal dissociation involving sensorimotor traumatic re-experiences and flash-
backs. 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 personal-
ities exist within the same person. This EP/ANP conflict 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 conflict between the EP and the
ANP intensify. During any new flashback, 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 field 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 defined as
an internal conflict 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 defining
structural dissociation in terms of two opposing personalities striving for
mutual destruction.
A classic example of such an inner conflict 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
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 per-
son, and therefore, it does not really matter whether Nick shoots him-
self or Michael shoots Nick. This duality represents the condition of the
posttraumatic survivor, constantly embroiled in an impossible conflict
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 final 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 struc-
tural 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 trans-
formed 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 conflict is characterized by uncontrollable rage that can-
not 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 significant 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 par-
ticular, re-experiencing in combination with avoidance/numbing symp-
toms appears to mediate between trauma and SIB (Weierich & Nock,
2008). As noted, the re-experiencing/avoidance conflict 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 conflict.
An important feature of severe and ongoing trauma such as trau-
matic 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 find a non-harm-
ful 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 medi-
ator between PTSD and SIB (Orth & Wieland, 2006).
In particular, studies reveal (Franklin, Posternak, & Zimmerman,
2002) that a group of subjects classified as suffering from C-PTSD
(e.g., PTSD with comorbid borderline personality disorder) exhib-
ited 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 significant 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. Specifically, this
study indicates that “the C-PTSD group have shown much greater phys-
ical aggression at this level than the PTSD group” (Dyer et al., 2009,
p. 1105). These findings 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 con-
tend that at least in some cases, the victim’s anger is directed inward.
Thus, we maintain that as posttraumatic symptoms become harsher:
(a) the conflict between the ANP and the EP intensifies, (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 pro-
cess 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 infor-
mation and even for emotional sustenance. Prolonged confinement in fear
of death and in isolation reliably produces a bond of identification 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-in-

juring 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 fun-
damental 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 flexible ability to become weaker or stronger in accord-
ance to varying conditions enables us to adapt to the world.
Despite this loss of the SBO’s flexibility, survivors must nevertheless
find 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 impli-
cations 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 acti-
vated 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.

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 attempt-
ing 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 bod-
ily 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 defined 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 flu, 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 cir-
cumstances the SBO shifts from Point A to Point B to Point C in accord-
ance with the situation and environmental conditions. Due to this
flexibility, the mechanism of the SBO enables us to adapt and function in
our environment.
(a)
A Too strong sense of body- ownership C
Sense of body- ownership
Default state (during our daily life)-D
B
Lack of sense of body- ownership
(b)
A+C
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 circum-

stances, the sense of ownership is transparent, flexible and changes frequently. We
move flexibly 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), figure 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 rep-
resent 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 sub-
ject 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 flexibility: 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 interme-
diate 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 sub-
ject adopts SIB to reduce the sense of ownership. Yet, as we saw, due
to the collapse of the flexible 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.
References
American Psychiatric Association. (1980). Diagnostic and statistical man-
ual of mental disorders (3rd ed.). Washington, DC: American Psychiatric
Association.
Arieli, A., & Ataria, Y. (in press). Helplessness: The inability to know-that you
don’t know-how. Philosophical Psychology.
Ataria, Y. (2015d). Where do we end and where does the world begin? The case
of insight meditation. Philosophical Psychology, 28(8), 1128–1146. https://
doi.org/10.1080/09515089.2014.969801.
Ataria, Y., Dor-Ziderman, Y., & Berkovich-Ohana, A. (2015). How does it feel
to lack a sense of boundaries? A case study of a long-term mindfulness medi-
tator. Consciousness and Cognition, 34, 133–147. https://doi.org/10.1016/j.
concog.2015.09.002.
Birmes, P., Brunet, A., Carreras, D., Ducassé, J. L., Charlet, J. P., Lauque, D.,
… Schmitt, L. (2003). The predictive power of peritraumatic dissociation and
acute stress symptoms for posttraumatic stress symptoms a three-month pro-
spective study. American Journal of Psychiatry, 160, 1337–1339.
Breh, D. C., & Seidler, G. H. (2007). Is peritraumatic dissociation a risk factor

for PTSD? Journal of Trauma & Dissociation, 8(1), 53–69.
Bremner, J. D., Southwick, S., Brett, E., Fontana, A., Rosenheck, R., &
Charney, D. S. (1992). Dissociation and posttraumatic stress disorder in
Vietnam combat veterans. The American Journal of Psychiatry, 149(3),
328–332.
Briere, J., Scott, C., & Weathers, F. (2005). Peritraumatic and persistent disso-
ciation in the presumed etiology of PTSD. American Journal of Psychiatry,
162(12), 2295–2301.
Candel, I., & Merckelbach, H. (2004). Peritraumatic dissociation as a predictor
of post-traumatic stress disorder: A critical review. Comprehensive Psychiatry,
45(1), 44–50.
Carlson, E. B., Dalenberg, C., & McDade-Montez, E. (2012). Dissociation
in posttraumatic stress disorder part I: Definitions and review of research.
Psychological Trauma: Theory, Research, Practice, and Policy, 4(5), 479–489.
https://doi.org/10.1037/a0027748.
Cimino, M. (Director). (1978). The deer hunter [motion picture].
Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A.
(2013). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent
profile analysis. European Journal of Psychotraumatology, 4(20706), 1–12.
https://doi.org/10.3402/ejpt.v4i0.20706.
Coppola, F. F. (Producer), Conrad, J. (Writer), & Coppola, F. F. (Director).
(1979). Apocalypse now [motion picture].
Courtois, C. A. (2004). Complex trauma, complex reactions: Assessment and
treatment. Psychotherapy: Theory, Research, Practice, Training, 41(4), 412–
425. https://doi.org/10.1037/0033-3204.41.4.412.
DePrince, A. P., Chu, A., & Visvanathan, P. (2006). Dissociation and posttrau-
matic stress disorder. PTSD Research Quarterly, 17(1), 1–8.
doi.org/10.1002/jclp.20619.
Franklin, C. L., Posternak, M. A., & Zimmerman, M. (2002). The impact of
subjective and expressed anger on the functioning of psychiatric outpatients
with post-traumatic stress disorder. Journal of Interpersonal Violence, 17(12),
1263–1273. https://doi.org/10.1177/088626002237855.
Psychology, 12(2), 95–107.
Gershuny, B. S., Cloitre, M., & Otto, M. W. (2003). Peritraumatic dissociation
and PTSD severity: Do event-related fears about death and control mediate
their relation? Behaviour Research and Therapy, 41(2), 157–166.
148 Y. ATARIA
Ginzburg, K., Butler, L. D., Saltzman, K., & Koopman, C. (2010). Dissociative
reactions in PTSD. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and
the dissociative disorders: DSM-V and beyond (pp. 457–469). New York:
Routledge.
Greenspan, G. S., & Samuel, S. E. (1989). Self-cutting after rape. The American
Journal of Psychiatry, 146(6), 789–790. https://doi.org/10.1176/
ajp.146.6.789.
Hagenaars, M. A., Van Minnen, A., & Hoogduin, K. A. (2010). The impact
of dissociation and depression on the efficacy of prolonged exposure treat-
ment for PTSD. Behaviour Research and Therapy, 48(1), 19–27. https://doi.
org/10.1016/j.brat.2009.09.001.
York Press.
doi.org/10.1002/jts.2490050305.
Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C.,
Bremner, J. D., & Spiegel, D. (2010). Emotion modulation in PTSD:
Clinical and neurobiological evidence for a dissociative subtype. American
Journal of Psychiatry, 167(6), 640–647. https://doi.org/10.1176/appi.
ajp.2009.09081168.
Marmar, C. R., Weiss, D., & Metzler, T. (1998). Peritraumatic dissociation and
posttraumatic stress disorder. In J. Bremner & C. Marmar (Eds.), Trauma, mem-
ory, and dissociation (pp. 229–252). Washington: American Psychiatric Press.
Psychiatry, 151(6), 902–907.
Marshall, G. N., & Schell, T. L. (2002). Reappraising the link between peritrau-
matic dissociation and PTSD symptom severity: Evidence from a longitudinal
study of community violence survivors. Journal of Abnormal Psychology, 111,
626–636.
Murray, J., Ehlers, A., & Mayou, R. (2002). Dissociation and post-traumatic
stress disorder: Two prospective studies of road traffic accident survivors. The
British Journal of Psychiatry, 180, 363–368.
Myers, C. (1940). Shell shock in France 1914–18. Cambridge: Cambridge
University Press.
Nijenhuis, E., Van der Hart, O., & Steele, K. (2010). Trauma-related structural
dissociation of the personality. Activitas Nervosa Superior, 52(1), 1–23.
Orth, U., & Wieland, E. (2006). Anger, hostility, and posttraumatic
stress disorder in trauma-exposed adults: A meta-analysis. Journal
of Consulting and Clinical Psychology, 74(4), 698–706. https://doi.
org/10.1037/0022-006x.74.4.698.
Reinders, T., Nijenhuis, S., Paans, J., Korf, J., Willemsen, M., & den Boer, A.
(2003). One brain, two selves. Neuroimage, 20(4), 2119–2125.
Resick, P. A., Bovin, M. J., Calloway, A. L., Dick, A. M., Kng, M. W., Mitchell,
K. S., … Wolf, E. J. (2012). A critical evaluation of the complex PTSD liter
ature: Implications for DSM-5. Journal of Traumatic Stress, 25(3), 241–251.
https://doi.org/10.1002/jts.21699.
Stovall-McClough, K. C., & Cloitre, M. (2006). Unresolved attachment,
PTSD, and dissociation in women with childhood abuse histories. Journal
org/10.1037/0022-006x.74.2.219.
Terr, L. C. (1991). Childhood traumas: An outline and overview. Journal of the
American Psychiatric Association, 148(1), 10–20. https://doi.org/10.1176/
foc.1.3.322.
Ursano, R. J., Fullerton, C. S., Epstein, R. S., Crowley, B., Vance, K., & Kao,
T. C. (1999). Peritraumatic dissociation and posttraumatic stress disorder fol-
lowing motor vehicle accidents. The American Journal of Psychiatry, 156(11),
1808–1810.
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. (1994). The body keeps the score: Memory and the evolv-
ing psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1(5),
253–265. https://doi.org/10.3109/10673229409017088.
Van der Kolk, B. A., & Fisler, R. (1995). Dissociation and the fragmentary nature
of traumatic memories: Overview and exploratory study. Journal of Traumatic
Stress, 8, 505–525. Retrieved January 11, 2011, from David Baldwins Trauma
Pages. http://www.trauma-pages.com/a/vanderk2.php.
150 Y. ATARIA
Van der Kolk, B. A., Pelcovitz, D., Roth, S., & Mandel, F. S. (1996).
Dissociation, somatization, and affect dysregulation: The complexity of adap-
tion to trauma. The American Journal of Psychiatry, 53 (Suppl.), 83–93.
1009–1020.
Waelde, L. C., Silvern, L., & Fairbank, J. A. (2005). A taxometric investigation
of dissociation in Vietnam veterans. Journal of Traumatic Stress, 18(4), 359–
369. https://doi.org/10.1002/jts.20034.
Weierich, M. R., & Nock, M. K. (2008). Posttraumatic stress symptoms medi-
ate the relation between childhood sexual abuse and nonsuicidal self-injury.
Journal of Consulting and Clinical Psychology, 76(1), 39–44. https://doi.
org/10.1037/0022-006x.76.1.39.
Wolf, E. J., Miller, M. W., Reardon, A. F., Ryabchenko, K. A., Castillo, D.,
& Freund, R. (2012). A latent class analysis of dissociation and post-
traumatic stress disorder: Evidence for a dissociative subtype. Archives
of General Psychiatry, 69(7), 698–705. https://doi.org/10.1001/
archgenpsychiatry.2011.1574.
Body-Disownership—Concluding
Remarks
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 mecha-
nism, defined in this book as body-disownership: One identifies the body
as one’s enemy. This mechanism, in turn, constitutes the nucleus of com-
plex 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 bound-
aries 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 sim-
ply, at-home. In contrast, when we find ourselves in more difficult cir-
cumstances, 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 sub-
ject–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 disrup-
tion 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

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 pro-
tect the victim during trauma; indeed, in many cases—even in the most
difficult situations—it does just that. Yet, in certain circumstances, the
very mechanism which should help us during trauma actually causes col-
lapse and harsh results over the long term.
This book has attempted to define 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 infinity, 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 victim-
izer 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 fixed, 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 con-
necting 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 pro-
found 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 com-
plex posttraumatic symptoms suggested in this book is certainly plausi-
ble. 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 defined as a condi-
tion 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
Scientific work must be supported by valid data. Chapter 2 of this book
is philosophical in nature and Chapters 3 and 4 rely mainly on experi-
mental 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 impossi-
ble 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 difficult when we realize that severe traumatic experiences are char-
acterized 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 dur-
ing traumatic events, such as blanking out, feeling like one is on auto-
matic 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” can-
not fully describe the subjective experience during trauma. In fact, it
seems that we cannot even distinguish questionnaires completed by a
traumatized individual from those filled in by someone using psychedelic

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 question-
naire, this remark is very specific. It raises doubts about the ability
of individuals currently suffering from PTSD and other dissocia-
tive symptoms to reflect 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 some-
times 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 scientific method, introspection presents

serious problems, at the very least in the case of severe and ongo-
ing 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 phe-
nomenological 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 phenomenologi-
cal 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-reflective 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 experi-
ence, and describe it with great precision” (Petitmengin, 2006, p. 229).
Furthermore, it allows us to get closer to the lived and subjective expe-
rience in general (Depraz, Varela, & Vermersch, 2003) and in particular
to the traumatic experience, which occurs at the bodily level and accord-
ingly 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 dis-
sociation during trauma.
As we saw, due to the difficulties resulting from the nature of
the peritraumatic dissociation experience, a survivor cannot reli-
ably complete the PDEQ. How can one reflect upon past experi-
ence if this event is fragmented and outside the autobiographical self?
Nevertheless, we contend that introspection can be achieved. The sur-
vivor can reflect upon traumatic experience by finding a way to recon-
struct 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 informa-
tion gained in semi-structured interviews neither reflects 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 with-
out the use of leading or intrusive questions makes it a valuable instru-
ment” (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 dif-
ficulty 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 difficulty recalling the exact tem-
poral 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—never-
theless, 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 difficult 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 define us
(Damásio, 1999) and, in many cases, the story of traumatic events
is simply too difficult 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 experi-
ence step by step, the survivor needs guidance. This process obviously
requires appropriate caution. Even though “people can be led to mis-
takenly 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 interfer-
ing 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 trau-
matic 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
flashbacks), 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 obvi-
ously not the only, way to examine this radical experience. Epoché
enables us to describe the pre-reflective 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 devel-
ops during severe trauma, we must find a way to penetrate the subjective
experience. Yet the traumatic experience transcends words, as is demon-
strated 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 con-
tinue 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 limita-
tions 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 five
patients (Invernizzi, et al., 2013, pp. 148–149 [Appendix]):
1As noted, Chapter 6 examines the consequences of trauma and not the traumatic expe-
rience 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 find
any in-depth phenomenological research on self-injury. Therefore, we used existing data
while noting the obvious limitations.
Interview (E = examiner; P = patient) Interpretation
E: Close your eyes and tell me if you feel when I’m touching your hand. This patient complains that his affected hand does nothing. Thus, he is sure that his
P: That’s not my hand!! real hand, not the one now attached to him, is functioning perfectly. The affected
E: What’s the problem with it? hand, however, does not function and hence, according to pure logic, it cannot
P: It’s not mine. I’ve already told this to the other doctor. Someone left it here. be his own hand. This patient has lost the ability to control his hand, yet denies
I don’t know who he was. this fact and instead has developed an explanation according to which the affected
E: What did the doctor tell you? hand simply cannot be his own. Surely, he believes, if the hand attached to his
P: He asked me whose hand was this one, but I don’t know who attached it to
162 Appendices
body were his own limb, he would be able to control it.

my body. The sense of disownership in this case ensues due to denial of the loss of SA
E: Can you move this hand? and not, so it seems, due to a lack of SBO. Thus, the fact that sense of limb-own-
P: No, it does not move. ership has not been damaged is responsible for C’s difficulty in accepting his new
E: Isn’t it a little bit weird to have a foreign hand with you? situation.
P: No! My hand is not like this! This is shorter, plus, it does nothing!! This patient’s sense of belief is so strong that it even allows him to look at his own
E: What is this hand doing here with you? hand and see it as shorter. We can see how the patient’s feelings are stronger than
P: Nothing. It does not move. It does nothing. knowledge. It thus seems that C suffers from two different kinds of deficits—
A second experimenter enters the room and asks: Good morning C, can you while the first (cognitive and neuronal) deficiency is a ssociated with the loss of
repeat your problem for me? Whose hand is this? SA, the second is associated with C’s ability to retain his delusional beliefs despite
P: I’ve already explained it. The problem is that this hand that cannot move is not clear-cut evidence.
mine. It’s not like mine.
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 you clap your hands?
P: I cannot, this hand does not move. But it is not mine. You can take it away.
(continued)
E: What is this? When discussing his affected hand, GB uses the word “could.” This word perfectly
P: It could be my hand. represents the inherent paradox GB is facing: the tension between what GB knows
E: Could? Whose hand is this? and what he feels. Indeed, when GB is asked directly whether the hand “is …
P: Mine or yours. It’s a female hand. It belongs to the nurse… but it’s wearing attached to your body or not?” his answer once again reveals the tension between
my pajamas… it’s strange. what he knows and what he feels: P: No. I don’t know. If GB had simply replied
negatively, this would not be a problem, yet he adds the words “I don’t know.”
Evidently on some level GB knows that the thesis he is attempting to construct is
somewhat problematic.
The examiner moves the pajamas out of GB’s line of vision and says: Whose GB strongly believes that the affected hand is not his own, a belief so strong that it
hand is this? has distorted (top-down) the way he views his affected hand—It’s a female hand…
GB touches the hand and says: I don’t know. I can feel if you pinch the right it’s not mine, it doesn’t look like mine. My hand is more thin and dry.
one, but when I pinch that hand I can’t feel I’m pinching. Obviously, it’s not GB has lost SA towards the affected hand as is reflected in his answer to the doctor:
mine. It’s yours. It’s not mine. It’s yours… I have no need for it. It doesn’t work… it does not move or
E: Where is your real hand? work like the right one. In thus describing his experience, he is in effect saying that
P: Here on the bed. he has lost control over the affected hand. Note the following paradox, however: If
E: If this hand isn’t yours, can I take it away with me? it is a women’s hand (It belongs to the nurse—Nadia) it could not be the doctor’s
P: Of course! If you want it, I will give it to you as my gift, since I have no hand. This indicates strong top-down influences. Ordinarily, cognitive processes
need for it. It doesn’t work. Maybe you’ll be able to get it to work. (both bottom-up and top-down) provide reciprocal feedback, which generates
E: Are you sad about having that hand with you? balance and enables us to operate in reality. The fact that the subject is less sensitive
P: Yes, a bit. I would like to understand why it does not move or work like the to information entering from the world (bottom-up) testifies to the power of the
right one. top-down processes that enable him to disregard changing information coming
E: Do you want to move this hand away? Wouldn’t you be sad without it? from the world. The subject is not really concerned whether this is a woman’s
P: Yes, if it was mine, but it’s not. hand or a man’s hand. Thus the subject is driven mainly by his new set of beliefs,
E: Would you prefer that this hand was not so close to your body? enabling him to disregard information coming from the outside
P: Yes, because it’s not mine, it doesn’t look like mine. My hand is more thin and (bottom-up). So long as the subject can disregard bottom-up information, he can
dry. easily retain these false beliefs. This is a vicious circle that reinforces itself.
E: Look at this hand, is it attached to your body or not? GB’s sense of disownership arises due to his denial of the loss of SA towards the
P: No. I don’t know… I do not feel it. affected limb. This denial becomes unbearable precisely because the sense of
E: The nurses told us you woke up last night and called them. Why? limb-ownership has not collapsed—at least not completely.
P: Because there was this hand here and I thought that Nadia forgot it and I In other words, disownership is the result of a conflict between one’s set of beliefs
wanted to give it back to her. She cannot work without it. Poor Nadia. and reality itself, that is, between top-down processes and bottom-up processes.
Appendices
E: Show me how you can clap your hands.

P: Impossible. Let’s try… No, I’m not doing it right, can’t you see? I can make
noise but I’m not really clapping.
163
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.
(continued)
E: Why are you here? MA serves as a perfect example of a strong sense of denial. MA’s sense of belief is so
P: I had a stroke. strong that he denies any association with the affected limb/side.
E: How are you now? All right? This belief allows MA to twist reality completely—he describes his affected hand as
P: No, I can’t move this arm. resting on his stomach while the doctor moves it in front of his face.
E: Your left arm? This example reveals that disownership is rooted in a sense of belief so strong that it
P: Yes, but the same is true for my left leg. The entire left side of my body is allows the subject to twist reality completely. The subject cannot accept his situa-
paralyzed. Do you think I will ever be better? I don’t think I will be able to
164 Appendices
tion and creates an alternative reality in which the hand attached to him could be
move them anymore. someone else’s limb.
E: Try to put your arms up like this. This can also be expressed in another way. The subject develops disownership
P: That hand does not move. The examiner brings MA’s left hand in front of because of what he does not know he knows, or more accurately, because of what
his face. he knows that he does not want to know. The subject knows that he will always
E: What is this thing in front of you? be paralyzed: I don’t think I will be able to move them anymore. Yet he prefers not
P: A hand. to know this information. This leads to the development of a whole set of beliefs
E: Whose hand is this? based on the desire not to know what he knows. Indeed, the information pursues
P: Yours! him, much like traumatic memory, and also manages him, leading to the creation
E: Mine? Are you sure? of a new world based upon the denial of reality.
P: Yes sure, whose hand is it supposed to be?
E: And where is your left hand?
P: On my stomach. Can’t you see?
E: So this hand isn’t yours.
P: No, my hand is on my stomach and cannot move.
E: Whose hand could this one be?
P: Yours of course. Are you joking? Why should it be mine? My hand is different,
not so heavy and it’s not there, I always keep it on my stomach.
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.
(continued)
E: How are you, Miss S? Clearly, Miss S has lost her SA towards the affected hand (it does not obey). She
P: Not fine, it does not work. identifies her left hand, yet she is sure that it is not her hand. In addition, Miss S
E: What does not work? is very clear that she wishes the doctor would take away her left hand (Surely, it
P: This arm (she touches her left hand), it does not move, it does not obey. is not mine. Take it away). Thus it becomes apparent that disownership, in this
E: I understand, but if I touch you there, can you feel it? case at least, is accompanied by a feeling that the subject needs to dispose of the
P: Yes, I do not know why but it does not obey. disowned hand.
E: Why are you here? The story of Miss S is clearly not rational (E: If it is not yours, whose hand is it? P:
P: For a stroke. Someone working here examined me before and hid his hand in my bed as a joke! …
E: Try to place your arms like this, as if you were holding up a tray. She raises E: Where is your real hand? P: I suppose he took my hand away and gave me this
her right arm. bad one! Go ask him!). Indeed, this reveals that disownership is accompanied by a
E: Can you do that? strong belief that the hand is not one’s own, a belief that exceeds knowledge and
P: No, the other hand (the left) is not working, it does not obey!! logical thinking. Denial of the loss of SA creates a new kind of logic that distorts
E: What’s that? reality.
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?
P: Surely, it is not mine. Take it away.
E: If it is not yours, whose hand is it?
P: Someone working here examined me before and hid his hand in my bed as a
joke! Give it back! What a joke!! I would prefer my hand; this one is too fat
and puffy!
E: Where is your real hand?
P: I suppose he took my hand away and gave me this bad one! Go ask him!
(continued)
Appendices
165
E: Hi, Mr. C, why are you here in this hospital? Mr. C portrays disownership accompanied by a strong sense of belief that allows
P: I had a stroke while I was on holiday. him to deny reality and construct an impossible situation: his hand is in fact the
E: What are your problems now? doctor’s hand. In this new reality, the doctor can have three hands. On some
P: The main problem is with the entire left side of my body. I cannot feel it or level, however, Mr. C is aware of the improbability of this theory. Yet even when
move it anymore. confronting this problem directly, he does not abandon his story.
E: Mr. C., look at this. What is this? The general conclusion here is particularly important. At the core of the disown-
P: Your hand. ership mechanism is a system that specializes in denying reality and in creating a
166 Appendices
E: My hand? Are you sure? top-down alternative that is not dependent upon information arriving from the
P: Yes, of course. It couldn’t be mine. bottom up.
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: (after placing his left hand near the patient’s hand): Can you choose your
own hand among these hands?
P: They are both yours.
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?
P: (smiling at the examiner). You are a polyp!
Bibliography
Alvarado, C. S. (2000). Out-of-body experiences. In E. E. Cardeña, S. J. Lynn,

& S. E. Krippner (Eds.), Varieties of anomalous experience: Examining the
scientific evidence (pp. 183–218). Washington, DC: American Psychological
Association.
American Psychiatric Association. (1980). Diagnostic and statistical man-
ual of mental disorders (3rd ed.). Washington, DC: American Psychiatric
Association.
Arieli, A., & Ataria, Y. (in press). Helplessness: The inability to know-that you
don’t know-how. Philosophical Psychology.
Arnold, L. (1995). Women and self-injury: A survey of 76 women. Bristol: Bristol
Crisis Service for Women.
Arzy, S., Thut, G., Mohr, C., Michel, C. M., & Blanke, O. (2006). Neural basis
of embodiment: Distinct contributions of temporoparietal junction and extra-
striate body area. Journal of Neuroscience, 26(31), 8074–8081.
Ataria, Y. (2010). Consciousness-body-time: How do people think lacking their body?
(MA thesis). The Hebrew University of Jerusalem.
Ataria, Y. (2015a). Dissociation during trauma: The Ownership-agency tradeoff
model. Phenomenology and the Cognitive Sciences, 14(4), 1037–1053. https://
doi.org/10.1007/s11097-014-9392-9.
Ataria, Y. (2015b). Sense of ownership and sense of agency during trauma.
Phenomenology and the Cognitive Sciences, 14(1), 199–212. https://doi.
org/10.1007/s11097-013-9334-y.

https://doi.org/10.1057/978-1-349-95366-0
168 Bibliography
Ataria, Y. (2015c). Trauma from an enactive perspective: The collapse of the

knowing-how structure. Adaptive Behavior, 23(3), 143–154. https://doi.
org/10.1177/1059712314578542.
Ataria, Y. (2015d). Where do we end and where does the world begin? The case
of insight meditation. Philosophical Psychology, 28(8), 1128–1146. https://
doi.org/10.1080/09515089.2014.969801.
Ataria, Y., & Neria, Y. (2013). Consciousness-body-time: How do people
think lacking their body? Humans Studies, 36(2), 159–178. https://doi.
org/10.1007/s10746-013-9263-3.
Ataria, Y., Dor-Ziderman, Y., & Berkovich-Ohana, A. (2015). How does it feel
to lack a sense of boundaries? A case study of a long-term mindfulness medi-
tator. Consciousness and Cognition, 34, 133–147. https://doi.org/10.1016/j.
concog.2015.09.002.
Baldwin, D. V. (2013). Primitive mechanisms of trauma response: An evolution-
ary perspective on trauma-related disorders. Neuroscience & Biobehavioral
Reviews, 37(8), 1549–1566.
Banks, G., Short, P., Martínez, A. J., Latchaw, R., Ratcliff, G., & Boller, F.
(1989). The alien hand syndrome. Clinical and postmortem findings. Archives
of Neurology, 46(4), 456–459.
Bedard-Gilligan, M., & Zoellner, L. A. (2012). Dissociation and memory frag-
mentation in post-traumatic stress disorder: An evaluation of the dissociative
encoding hypothesis. Memory, 20(3), 277–299.
Bennun, I. (1984). Psychological models of self-mutilation. Suicide and Life-
Threatening Behavior, 14(3), 166–186.
Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity
of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735.
Biran, I., Giovannetti, T., Buxbaum, L., & Chatterjee, A. (2006). The alien hand
syndrome: What makes the alien hand alien? Cognitive Neuropsychology, 23(4),
563–582. https://doi.org/10.1080/02643290500180282.
Birmes, P., Brunet, A., Carreras, D., Ducassé, J. L., Charlet, J. P., Lauque, D., …
& Schmitt, L. (2003). The predictive power of peritraumatic dissociation and
acute stress symptoms for posttraumatic stress symptoms a three-month pro-
spective study. American Journal of Psychiatry, 160(7), 1337–1339.
Blanke, O. (2012). Multisensory brain mechanisms of bodily self-consciousness.
Nature Reviews Neuroscience, 13(8), 556–571.
Blanke, O., & Metzinger, T. (2008). Full-body illusions and minimal phe-
nomenal selfhood. Trends in Cognitive Sciences, 13(1), 7–13. https://doi.
org/10.1016/j.tics.2008.10.003.
Blanke, O., & Mohr, C. (2005). Out-of-body experience, heautoscopy,
and autoscopic hallucination of neurological origin implications for
Bibliography 169
neurocognitive mechanisms of corporeal awareness and self consciousness.

Brain Research Reviews, 50(1), 184–199. https://doi.org/10.1016/j.
brainresrev.2005.05.008.
Blanke, O., Arzy, S., & Landis, T. (2008). Illusory perceptions of the human
body and self. In G. Goldenberg, & B. Miller (Eds.), Handbook of clinical
neurology. Neuropsychology and behavioral neurology (Vol. 88, pp. 1–594).
https://www.sciencedirect.com/science/journal/00729752/88.
Blanke, O., Landis, T., Spinelli, L., & Seeck, M. (2004). Out-of-body experi-
ence and autoscopy of neurological origin. Brain, 127(2), 243–258. http://
dx.doi.org/10.1093/brain/awh040.
Blanke, O., Morgenthaler, F. D., Brugger, P., & Overney, L. S. (2009).
Preliminary evidence for a fronto‐parietal dysfunction in able‐bodied partic-
ipants with a desire for limb amputation. Journal of Neuropsychology, 3(2),
181–200. https://doi.org/10.1348/174866408x318653.
Bogen, J. E. (1993). The callosal syndromes. In K. M. Heilman, & E. Valenstein
(Eds.), Clinical neuropsychology (3rd ed., pp. 337–407). New York: Oxford
University Press.
Botvinick, M., & Cohen, J. (1998). Rubber hand ‘‘feel’’ touch that eyes see.
Nature, 391, 756.
Boudewyn, A. C., & Liem, J. H. (1995). Childhood sexual abuse as a precur-
sor to depression and self-destructive behavior in adulthood. Journal of
Traumatic Stress, 8(3), 445–459. https://doi.org/10.1002/jts.2490080307.
Bracha, S. H. (2004). Freeze, flight, fight, fright, faint: Adaptationist perspectives
on the acute stress response spectrum. CNS Spectrums, 9(9), 679–685.
Breh, D. C., & Seidler, G. H. (2007). Is peritraumatic dissociation a risk factor
for PTSD? Journal of Trauma & Dissociation, 8(1), 53–69.
Bremner, J. D., Southwick, S., Brett, E., Fontana, A., Rosenheck, R., &
Charney, D. S. (1992). Dissociation and posttraumatic stress disorder in
Vietnam combat veterans. The American Journal of Psychiatry, 149(3),
328–332.
Brewin, C. R. (2007). Autobiographical memory for trauma: Update on four
controversies. Memory, 15(3), 227–248.
Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of posttraumatic
stress disorder. Clinical Psychology Review, 23(3), 339–376.
Briere, J., Scott, C., & Weathers, F. (2005). Peritraumatic and persistent disso-
ciation in the presumed etiology of PTSD. American Journal of Psychiatry,
162(12), 2295–2301.
Brion, S., & Jedynak, C. P. (1972). Troubles du transfert interhemispherique. A
propos de trois observations de tumeurs du corps calleux. Le signe de la main.
Revue Neurologique, 126(4), 257–266.
Brooks, R., Bryant, R. A., Silove, D., Creamer, M., O’Donnell, M., McFarlane,
A. C., & Marmar, C. R. (2009). The latent structure of the peritraumatic dis-
sociative. Journal of Traumatic Stress, 22(2), 153–157.
170 Bibliography
Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002). Reasons for suicide
attempts and nonsuicidal self-injury in women with borderline personal-
ity disorder. Journal of Abnormal Psychology, 111(1), 198–202. https://doi.
org/10.1037/0021-843x.111.1.198.
Brugger, P., Lenggenhager, B., & Giummarra, M. J. (2013). Xenomelia: A social
neuroscience view of altered bodily self-consciousness. Frontiers in Psychology,
4(204), 1–7. https://doi.org/10.3389/fpsyg.2013.00204.
Brugger, P., Regard, M., & Landis, T. (1997). Illusory reduplication
of one’s own body: Phenomenology and classification of autoscopic
phenomena. Cognitive Neuropsychiatry, 2(1), 19–38. https://doi.
org/10.1080/135468097396397.
Candel, I., & Merckelbach, H. (2004). Peritraumatic dissociation as a predictor
of post-traumatic stress disorder: A critical review. Comprehensive Psychiatry,
45(1), 44–50.
Carlson, E. B., Dalenberg, C., & McDade-Montez, E. (2012). Dissociation
in posttraumatic stress disorder part I: Definitions and review of research.
Psychological Trauma: Theory, Research, Practice, and Policy, 4(5), 479–489.
https://doi.org/10.1037/a0027748.
Cimino, M. (Director). (1978). The deer hunter [motion picture].
Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A.
(2013). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent
profile analysis. European Journal of Psychotraumatology, 4(20706), 1–12.
https://doi.org/10.3402/ejpt.v4i0.20706.
Cogliano, R., Crisci, C., Conson, M., Grossi, D., & Trojano, L. (2012). Chronic
somatoparaphrenia: A follow-up study on two clinical cases. Cortex, 48(6),
758–767. https://doi.org/10.1016/j.cortex.2011.08.008.
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.
Coltheart, M. (2010). The neuropsychology of delusions. Annals of the New
York Academy of Sciences, 1191(1), 16–26.
Coppola, F. F. (Producer), Conrad, J. (Writer), & Coppola, F. F. (Director).
(1979). Apocalypse now [motion picture].
Courtois, C. A. (2004). Complex trauma, complex reactions: Assessment and
treatment. Psychotherapy: Theory, Research, Practice, Training, 41(4), 412–
425. https://doi.org/10.1037/0033-3204.41.4.412.
Craig, A. D. (2003). Interoception: The sense of the physiological condition of
the body. Current Opinion in Neurobiology, 13(4), 500–505.
Bibliography 171
Critchley, M. (1953). The parietal lobe. New York: Hafner Press.

Critchley, M. (1973). Misoplegia or hatred of hemiplegia. Mount Sinai Journal
of Medicine, 41(1), 82–87.
Critchley, H. D., & Harrison, N. A. (2013). Visceral influences on brain and
behavior. Neuron, 77(4), 624–638.
Curran, H. V., & Morgan, C. (2000). Cognitive, dissociative and psy-
chotogenic effects of ketamine in recreational users on the night of
drug use and 3 days later. Addiction, 95(4), 575–590. https://doi.
org/10.1046/j.1360-0443.2000.9545759.x.
Damásio, A. (1994). Descartes’ error: Emotion, reason, and the human brain.
Putnam: New York.
Damásio, A. (1999). The feeling of what happens: Body and emotion in the making
of consciousness. New York: Harcourt Brace & Company.
Damásio, A. (2003). Looking for Spinoza: Joy, sorrow, and the feeling brain.
Orlando: Harcourt.
Damásio, A. (2010). Self comes to mind: Constructing the conscious brain. New
York: Pantheon Books.
Davies, M., Coltheart, M., Langdon, R., & Breen, N. (2002). Monothematic
delusions: Towards a two-factor account. Philosophy, Psychiatry and Psychology,
8(2–3), 133–158. https://doi.org/10.1353/ppp.2001.0007.
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.
De Preester, H., & Tsakiris, M. (2009). Body-extension versus body-incorpo-
ration: Is there a need for a body-model? Phenomenology and the Cognitive
Sciences, 8(3), 307–319.
de Saint-Exupéry, A. (1971). The little prince (K. Woods, Trans.).
Harmondsworth, Midd: Penguin Books.
de Vignemont, F. (2007). Habeas Corpus: The sense of ownership of
org/10.1111/j.1468-0017.2007.00315.x.
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.
de Vignemont, F. (2016). Pain and the spatial boundaries of the bodily self.
In L. Garcia-Larrea, & P. Jackson (Eds.), Pain and the conscious brain (pp.
1–12). International Association for the Study of Pain.
de Vignemont, F. (2017). Mind the body. Oxford: Oxford University Press.
Debruyne, H., Portzky, M., Peremans, K. P., & Audenaert, K. (2011). Cotard’s
Syndrome. Mind & Brain, The Journal of Psychiatry, 2(1), 67–72.
Degenaar, J. (2012). Perceptual engagement. Antwerpen: University of Antwerp.
172 Bibliography
Degenaar, J. (2013). Through the inverting glass: First-person observations on

spatial vision and imagery. Phenomenology and the Cognitive Sciences, 13(2),
373–393.
Della Sala, S., Marchetti, C., & Spinnler, H. (1994). The anarchic hand: A fron-
tomesial sign. In F. Boller, & J. Grafman (Eds.), Handbook of neuropsychology
(Vol. IX, pp. 233–255). Amsterdam: Elsevier.
Depraz, N., Varela, F., & Vermersch, P. (Eds.). (2003). On becoming aware: A
pragmatics of experiencing. Amsterdam: John Benjamins.
DePrince, A. P., Chu, A., & Visvanathan, P. (2006). Dissociation and posttrau-
matic stress disorder. PTSD Research Quarterly, 17(1), 1–8.
Dieguez, S. (2013). Doubles everywhere: Literary contributions to the study of
the bodily self. In J. Bogousslavsky, & D. S (Eds.), Literary medicine: Brain
disease and doctors in novels, theater, and film (Vol. 31, pp. 77–115). Basel:
Karger Publishers. https://doi.org/10.1159/000345912.
Dieguez, S., & Lopez, C. (2017). The bodily self: Insights from clinical and
experimental research. Annals of Physical and Rehabilitation Medicine, 60(3),
198–207. https://doi.org/10.1016/j.rehab.2016.04.007.
Dillon, M. C. (1998). Sartre on the phenomenal body and Merleau-Ponty’s cri-
tique. In J. Stewart (Ed.), The debate between Sartre and Merleau-Ponty (pp.
121–143). Evanston: Northwestern University Press.
London, New York: Rowman & Littlefield International.
Dubo, E. D., Zanarini, M. C., Lewis, R. E., & Williams, A. A. (1997).
Childhood antecedents of self-destructiveness in borderline personal-
ity disorder. Canadian Journal of Psychiatry, 42(1), 63–69. https://doi.
org/10.1177/070674379704200110.
doi.org/10.1002/jclp.20619.
Ehlers, A., & Clark, D. (2000). A cognitive model of posttraumatic stress disor-
der. Behaviour Research and Therapy, 38, 319–345.
Ehlers, A., Hackmann, A., & Michael, T. (2004). Intrusive re-experiencing in
post-traumatic stress disorder: Phenomenology, theory, and therapy. Memory,
12(4), 403–415.
Fanon, F. (1968). The wretched of the earth (C. Farrington, Trans.). New York:
Grove Press.
Farrer, C., Bouchereau, M., Jeannerod, M., & Franck, N. (2008). Effect of dis-
torted visual feedback on the sense of agency. Behavioural Neurology, 19(1–2),
53–57.
Farrer, C., Franck, N., Georgieff, N., Frith, C., Decety, J., & Jeanneroda, M.
(2003). Modulating the experience of agency: A positron emission tomogra-
phy study. NeuroImage, 18, 324–333.
Bibliography 173
Favazza, A. R. (1989). Why patients mutilate themselves. Psychiatric Services,

40(2), 137–145. https://doi.org/10.1176/ps.40.2.137.
Favazza, A. R. (1998). The coming of age of self-mutilation. Journal of Nervous
& Mental Diseased, 186(5), 259–268.
Favazza, A. R., & Conterio, K. (1988). The plight of chronic self-mutila-
tors. Community Mental Health Journal, 24(1), 22–30. https://doi.
org/10.1007/bf00755050.
Feinberg, T. E., Venneri, A., Simone, A. M., Fan, Y., & Northoff, G. (2010).
The neuroanatomy of asomatognosia and somatoparaphrenia. Journal
of Neurology, Neurosurgery & Psychiatry, 81(3), 276–281. https://doi.
org/10.1136/jnnp.2009.188946.
First, M. B., & Fisher, C. E. (2011). Body integrity identity disorder: The per-
sistent desire to acquire a physical disability. Psychopathology, 45(1), 3–14.
https://doi.org/10.1159/000330503.
Fisher, K., & Smith, R. (2000). More work is needed to explain why patients
ask for amputation of healthy limbs. BMJ, 320(7242), 1147. http://dx.doi.
org/10.1136/bmj.320.7242.1147/a.
Fleminger, S., & Burns, A. (1993). The delusional misidentification syndromes
in patients with and without evidence of organic cerebral disorder: A struc-
tured review of case reports. Biological Psychiatry, 1, 22–32. https://doi.
org/10.1016/0006-3223(93)90274-h.
Fotopoulou, A., Jenkinson, P. M., Tsakiris, M., Haggard, P., Rudd, A.,
& Kopelman, M. D. (2011). Mirror-view reverses somatoparaphrenia:
Dissociation between first-and third-person perspectives on body owner-
ship. Neuropsychologia, 49(14), 3946–3955. https://doi.org/10.1016/j.
neuropsychologia.2011.10.011.
Franklin, C. L., Posternak, M. A., & Zimmerman, M. (2002). The impact of
subjective and expressed anger on the functioning of psychiatric outpatients
with post-traumatic stress disorder. Journal of Interpersonal Violence, 17(12),
1263–1273. https://doi.org/10.1177/088626002237855.
Frith, C. D., Blakemore, S. J., & Wolpert, D. M. (2000). Abnormalities in the
awareness and control of action. Philosophical Transactions of the Royal Society
of London. Series B: Biological Sciences, 355(1404), 1771–1788.
Psychology, 12(2), 95–107.
Fuchs, T., & Schlimme, J. E. (2009). Embodiment and psychopathology: A phe-
nomenological perspective. Current Opinion in Psychiatry, 22(6), 570–575.
https://doi.org/10.1097/yco.0b013e3283318e5c.
Furth, G., & Smith, R. (2000). Apotemnophia: Information, questions, answers, and
recommendations about self-demand amputation. Bloomington: 1st Books Library.
174 Bibliography
Gallagher, S. (1995). Body schema and intentionality. In J. L. Bermudez, A.

Marcel, & N. Eilan (Eds.), The body and the self (pp. 225–244). Cambridge
and London: MIT press.
Gallagher, S. (2000). Philosophical conceptions of the self: Implications for
cognitive science. Trends in Cognitive Sciences, 4(1), 14–21. https://doi.
org/10.1016/s1364-6613(99)01417-5.
Gallagher, S. (2003). Bodily self-awareness and object-perception. Theoria et
Historia Scientiarum: International Journal for Interdisciplinary Studies, 7(1),
53–68.
Press.
Gallagher, S. (2007). The natural philosophy of agency. Philosophy Compass, 2(2),
347–357. https://doi.org/10.1111/j.1747-9991.2007.00067.x.
Gallagher, S. (2011). Multiple aspects in the sense of agency. New Ideas in Psychology,
30(1), 15–31. https://doi.org/10.1016/j.newideapsych.2010.03.003.
Gallagher, S. (2017). Enactivist interventions: Rethinking 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., & Sørensen, J. B. (2006). Experimenting with phenomenology.
Consciousness and Cognition, 15, 119–134.
Gallagher, S., & Zahavi, D. (2008). The phenomenological mind: An introduction
to philosophy of mind and cognitive science. London: Routledge.
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.
Gershuny, B. S., Cloitre, M., & Otto, M. W. (2003). Peritraumatic dissociation
and PTSD severity: Do event-related fears about death and control mediate
their relation? Behaviour Research and Therapy, 41(2), 157–166.
Gerstmann, J. (1942). Problem of imperception of disease and of impaired body
territories with organic lesions: Relation to body scheme and its disorders.
Archives of Neurology and Psychiatry, 48(6), 890–913.
Gibbs R. W. G. (2006). Embodiment and Cognitive Science. New York:
Cambridge University Press.
Gibson, J. (1979). The ecological approach to visual perception. Hillsdale, NJ:
Lawrence Erlbaum.
Ginzburg, K., Butler, L. D., Saltzman, K., & Koopman, C. (2010). Dissociative
reactions in PTSD. In P. F. Dell, & J. A. O’Neil (Eds.), Dissociation and
the dissociative disorders: DSM-V and beyond (pp. 457–469). New York:
Routledge.
Giummarra, M. J., Bradshaw, J. L., Nicholls, M. E., Hilti, L. M., & Brugger,
P. (2011). Body integrity identity disorder: Deranged body processing, right
Bibliography 175
fronto-parietal dysfunction, and phenomenological experience of body incon-

gruity. Neuropsychology Review, 21(4), 320–333. https://doi.org/10.1007/
s11065-011-9184-8.
Gratz, K. L. (2003). Risk factors for and functions of deliberate self-harm: An
empirical and conceptual review. Clinical Psychology: Science and Practice,
10(2), 192–205. https://doi.org/10.1093/clipsy.bpg022.
Gratz, K. L., Conrad, S. D., & Roemer, L. (2002). Risk factors for deliberate
self-harm among college students. American Journal of Orthopsychiatry,
72(1), 128–140.
Greenspan, G. S., & Samuel, S. E. (1989). Self-cutting after rape. The American
Journal of Psychiatry, 146(6), 789–790. https://doi.org/10.1176/
ajp.146.6.789.
Hagenaars, M. A., Van Minnen, A., & Hoogduin, K. A. (2010). The impact
of dissociation and depression on the efficacy of prolonged exposure treat-
ment for PTSD. Behaviour Research and Therapy, 48(1), 19–27. https://doi.
org/10.1016/j.brat.2009.09.001.
Hall, P., & Steinberg, M. (1994). Systematic assessment of dissociative symptoms
and disorders using the SCID-D in a clinical outpatient setting: Three cases.
Dissociation: Progress in the Dissociative Disorders, VII(2), 112–116.
Halligan, P. W., Marshall, J. C., & Wade, D. T. (1995). Unilateral somatopara-
phrenia after right hemisphere stroke: A case description. Cortex, 31(1), 173–
182. https://doi.org/10.1016/s0010-9452(13)80115-3.
Hawton, K., Rodham, K., Evans, E., & Weatherall, R. (2002). Deliberate
self harm in adolescents: Self report survey in schools in England. British
Medical Journal, 325(7374), 1207–1211. https://doi.org/10.1136/
bmj.325.7374.1207.
York Press.
doi.org/10.1002/jts.2490050305.
Herpertz, S. (1995). Self-injurious behaviour. Psychopathological and nosologi-
cal characteristics in subtypes of self-injurers. Acta Psychiatrica Scandinavica,
91(1), 57–68.
176 Bibliography
Hilti, L. M., & Brugger, P. (2010). Incarnation and animation: Physical ver-
sus representational deficits of body integrity. Experimental Brain Research,
204(3), 315–326. https://doi.org/10.1007/s00221-009-2043-7.
Hilti, L. M., Hanggi, J., Vitacco, D. A., Kraemer, B., Palla, A., Luechinger, R.,
… Brugger, P. (2013). The desire for healthy limb amputation: Structural
brain correlates and clinical features of xenomelia. Brain, 136(1), 318–329.
https://doi.org/10.1093/brain/aws316.
Husserl, E. (1936/1970). The crisis of European sciences and transcendental phe-
nomenology: An introduction to phenomenological philosophy (D. Carr, Trans.).
Evanston: Northwestern University Press.
Husserl, E. (1989). Ideas pertaining to a pure phenomenology and to a phenomeno-
logical philosophy—Second book: Studies in the phenomenology of constitution (R.
Rojcewicz, & A. Schuwer, Trans.). Dordrecht: Kluwer.
Invernizzi, P., Gandola, M., Romano, D., Zapparoli, L., Bottini, G., & Paulesu,
E. (2013). What is mine? Behavioral and anatomical dissociations between
somatoparaphrenia and anosognosia for hemiplegia. Behavioural Neurology,
26(1–2), 139–150.
James, W. (1890). The principles of psychology (Vol. 1). London: Macmillan.
Janet, P. (1889). L’automatisme psychologique. Paris: Alcan.
Janet, P. (1925). Psychological healing; A historical and clinical study (E. Paul, &
C. Paul, Trans.). New York: Macmillan.
Jaspers, K. (1963). General psychopathology. Chicago: University of Chicago Press.
Kalckert, A., & Ehrsson, H. (2012). Moving a rubber hand that feels like
your own: A dissociation of ownership and agency. Frontiers in Human
Neuroscience, 6(40), 1–14. https://doi.org/10.3389/fnhum.2012.00040.
Karnath, H. O., & Baier, B. (2010). Right insula for our sense of limb owner-
ship and self-awareness of actions. Brain Structure and Function, 214(5–6),
411–417.
Kemperman, I., Russ, M. J., & Shearin, E. (1997). Self-injurious behavior and
mood regulation in borderline patients. Journal of Personality Disorders,
11(2), 146–157. https://doi.org/10.1521/pedi.1997.11.2.146.
Kim. (1993). Untitled. The Cutting Edge: A Newsletter for Women Living with
Self-inflicted Violence, 4(3), 3–4.
Kokkinara, E., Kilteni, K., Blom, K. J., & Slater, M. (2016). First person per-
spective of seated participants over a walking virtual body leads to illusory
agency over the walking. Scientific Reports, 6(28879), 1–11. https://doi.
org/10.1038/srep28879.
Kozlowska, K., Walker, P., McLean, L., & Carrive, P. (2015). Fear and the defense
cascade: Clinical implications and management. Harvard Review of Psychiatry,
23(4), 263–287. https://doi.org/10.1097/hrp.0000000000000065.
Krans, J., Näring, G., Becker, E. S., & Holmes, E. (2009). Intrusive trauma
memory: A review and functional analysis. Applied Cognitive Psychology, 23(8),
1076–1088.
Bibliography 177
Kritikos, A., Breen, N., & Mattingley, J. B. (2005). Anarchic hand syndrome:
Bimanual coordination and sensitivity to irrelevant information in uni-
manual reaches. Cognitive Brain Research, 24(3), 634–647. https://doi.
org/10.1016/j.cogbrainres.2005.03.015.
Lakoff, G., & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and
its challenge to western thought. New York: Basic Books.
Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C.,
Bremner, J. D., & Spiegel, D. (2010). Emotion modulation in PTSD:
Clinical and neurobiological evidence for a dissociative subtype. American
Journal of Psychiatry, 167(6), 640–647. https://doi.org/10.1176/appi.
ajp.2009.09081168.
Laub, D. (1995). Truth and testimony: The process and the struggle. In
C. Caruth (Ed.), Trauma: Explorations in memory (pp. 61–45). Baltimore,
MD: The Johns Hopkins University Press.
Laye-Gindhu, A., & Schonert-Reichl, K. A. (2005). Nonsuicidal self-harm
among community adolescents: Understanding the “whats” and “whys” of
self-harm. Journal of Youth and Adolescence, 34(5), 447–457. https://doi.
org/10.1007/s10964-005-7262-z.
Legrand, D. (2006). The bodily self: The sensori-motor roots of pre-reflective
self-consciousness. Phenomenology and the Cognitive Sciences, 5(1), 89–118.
Legrand, D. (2007). Pre-reflective self-consciousness: On being bodily in the
world. Janus Head, 9(2), 493–519.
Leiguarda, R., Starkstein, S., & Berthier, M. (1989). Anterior callosal haemor-
rhage. A partial interhemispheric disconnection syndrome. Brain, 112, 1019–
1037. http://dx.doi.org/10.1093/brain/112.4.1019.
Levi, P. (1959). If this is a man (S. Woolf, Trans.). New York: The Orion Press.
Levi, P. (1993). The drowned and the saved (R. Rosenthal, Trans.). London: Abacus.
Lewis, J. S., Kersten, P., McCabe, C. S., McPherson, K. M., & Blake, D. R.
(2007). Body perception disturbance: A contribution to pain in complex
regional pain syndrome (CRPS). Pain, 133(1), 111–119.
Linehan, M. (1993). Cognitive–behavioral treatment for borderline personality dis-
order. New York: Guilford Press.
Loetscher, T., Regard, M., & Brugger, P. (2006). Misoplegia: A review of the lit-
erature and a case without hemiplegia. Journal of Neurology, Neurosurgery &
Psychiatry, 77(9), 1099–1100. https://doi.org/10.1136/jnnp.2005.087163.
Lopez, C., Halje, P., & Blanke, O. (2008). Body ownership and embodiment:
Vestibular and multisensory mechanisms. Clinical Neurophysiology, 38(3),
149–161. https://doi.org/10.1016/j.neucli.2007.12.006.
Mailis, A. (1996). Compulsive targeted self-injurious behaviour in humans
with neuropathic pain: A counterpart of animal autotomy? Four case
reports and literature review. Pain, 64(3), 569–578. https://doi.
org/10.1016/0304-3959(95)00173-5.
178 Bibliography
Maravita, A., Spence, C., & Driver, J. (2003). Multisensory integration and the
body schema: Close to hand and within reach. Current Biology, 13, 531–539.
Marchetti, C., & Sala, S. D. (1998). Disentangling the alien and anar-
chic hand. Cognitive Neuropsychiatry, 3(3), 191–207. https://doi.
org/10.1080/135468098396143.
Marmar, C. R., Weiss, D., & Metzler, T. (1998). Peritraumatic dissociation and
posttraumatic stress disorder. In J. Bremner, & C. Marmar (Eds.), Trauma,
memory, and dissociation (pp. 229–252). Washington, DC: American
Psychiatric Press.
Psychiatry, 151(6), 902–907.
Marshall, G. N., & Schell, T. L. (2002). Reappraising the link between peritraumatic
dissociation and PTSD symptom severity: Evidence from a longitudinal study of
community violence survivors. Journal of Abnormal Psychology, 111, 626−636.
Maselli, A., & Slater, M. (2013). The building blocks of the full body owner-
ship illusion. Frontiers in Human Neuroscience, 7(83), 1–15https://doi.
org/10.3389/fnhum.2013.00083.
Mazelis, R. (1998). The Cutting Edge: A Newsletter for Women Living with Self-
inflicted Violence, 9(3 [35]), 1–11.
McLane, J. (1996). The voice on the skin: Self‐mutilation and Merleau‐Ponty’s
theory of language. Hypatia: A Journal of Feminist Philosophy, 11(4), 107–
118. https://doi.org/10.1111/j.1527-2001.1996.tb01038.x.
McNally, R. J. (2003a). Remembering trauma. Cambridge, MA: Belknap Press
of Harvard University Press.
McNally, R. J. (2003b). Psychological mechanisms in acute response to trauma.
Society of Biological Psychiatry, 53(9), 779–788. https://doi.org/10.1016/
s0006-3223(02)01663-3.
Merleau-Ponty, M. (1968). The visible and the invisible (C. Lefort, Ed., & A.
Lingis, Trans.). Evanston: Northwestern University Press.
Merleau-Ponty, M. (1973). The prose of the world (C. Lefort, Ed., & J. O’Neill,
Trans.). Evanston: Northwestern University Press.
Morgan, H. L., Turner, D. C., Corlett, P. R., Absalom, A. R., Adapa, R., Arana,
F. S., … Fletcher, P. C. (2011). Exploring the impact of ketamine on the
experience of illusory body ownership. Biological Psychiatry, 69(1), 35–41.
https://doi.org/10.1016/j.biopsych.2010.07.032.
Moseley, L., Olthof, N., Venema, A., Don, S., Wijers, M., Gallace, A., & Spence,
C. (2008). Psychologically induced cooling of a specific body part caused by
Bibliography 179
the illusory ownership of an artificial counterpart. Proceedings of the National

Academy of Sciences of the USA, 35(5), 13169–13173.
Moss, A. D., & Turnbull, O. H. (1996). Hatred of the hemiparetic limbs
(misoplegia) in a 10 year old child. Journal of Neurology, Neurosurgery, and
Psychiatry, 61(2), 210.
Murray, C. (2004). An interpretative phenomenological analysis of the embod-
iment of artificial limbs. Disability and Rehabilitation, 26(16), 963–973.
https://doi.org/10.1080/09638280410001696764.
Murray, J., Ehlers, A., & Mayou, R. (2002). Dissociation and post-traumatic
stress disorder: Two prospective studies of road traffic accident survivors. The
British Journal of Psychiatry, 180, 363–368.
Myers, C. (1940). Shell shock in France 1914–18. Cambridge: Cambridge
University Press.
Nijenhuis, E., Van der Hart, O., & Steele, K. (2010). Trauma-related structural
dissociation of the personality. Activitas Nervosa Superior, 52(1), 1–23.
Nock, M. K. (2008). Actions speak louder than words: An elaborated theo-
retical model of the social functions of self-injury and other harmful behav-
iors. Applied and Preventive Psychology, 12(4), 159–168. https://doi.
org/10.1016/j.appsy.2008.05.002.
Nock, M. K. (2010). Self-injury. The Annual Review of Clinical Psychology, 6,
339–369. https://doi.org/10.1146/annurev.clinpsy.121208.131258.
Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment
of self-mutilative behavior. Journal of Consulting and Clinical Psychology,
75(2), 885–890. https://doi.org/10.1037/0022-006x.72.5.885.
Nock, M. K., & Prinstein, M. J. (2005). Contextual features and
behavioral functions of self-mutilation among adolescents.
Journal of Abnormal Psychology, 114(1), 140–146. https://doi.
org/10.1037/0021-843x.114.1.140.
O’Regan, K. J. (2010). Explaining what people say about sensory qualia. In N.
Gangopadhyay, M. Madary, & F. Spicer (Eds.), Perception, action, and con-
sciousness (pp. 31–50). Oxford: Oxford University Press.
Orth, U., & Wieland, E. (2006). Anger, hostility, and posttraumatic
stress disorder in trauma-exposed adults: A meta-analysis. Journal
org/10.1037/0022-006x.74.4.698.
O’Shaughnessy, B. (2000). Consciousness and the world. Oxford: Clarendon
Press.
180 Bibliography
Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2008). Predictors of
posttraumatic stress disorder and symptoms in adults: A meta-analysis.
Psychological Trauma: Theory, Research, Practice, and Policy, S(1), 3–36.
Pearce, J. M. (2007). Misoplegia. European Neurology, 57(1), 62–64. https://
doi.org/10.1159/000102172.
Petitmengin, C. (2006). Describing one’s subjective experience in the second
person: An interview method for the science of consciousness. Phenomenology
and the Cognitive Sciences, 5, 229–269.
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.
Porter, S., & Peace, K. A. (2007). The scars of memory. Psychological Science,
18(5), 435–441.
Rahmanovic, A., Barnier, A. J., Cox, R. E., Langdon, R., & Coltheart, M.
(2012). “That’s not my arm”: A hypnotic analogue of somatoparaphrenia.
Cognitive Neuropsychiatry, 17(1), 36–63. https://doi.org/10.1186/cc12494.
Ramachandran, V. S., & Blakeslee, S. (1998). Phantoms in the brain. New York:
Quill William Morrow.
Reinders, T., Nijenhuis, S., Paans, J., Korf, J., Willemsen, M., & den Boer, A.
(2003). One brain, two selves. NeuroImage, 20(4), 2119–2125.
Resick, P. A., Bovin, M. J., Calloway, A. L., Dick, A. M., Kng, M. W., Mitchell,
K. S., … Wolf, E. J. (2012). A critical evaluation of the complex PTSD liter-
ature: Implications for DSM‐5. Journal of Traumatic Stress, 25(3), 241–251.
https://doi.org/10.1002/jts.21699.
Richardson, L. (2013). Bodily sensation and tactile perception. Philosophy and
Phenomenological Research, 86(1), 134–154.
Romano, D., Gandola, M., Bottini, G., & Maravita, A. (2014). Arousal
responses to noxious stimuli in somatoparaphrenia and anosognosia: Clues to
body awareness. Brain, 1–11. https://doi.org/10.1093/brain/awu009.
Ross, S., & Heath, N. L. (2003). Two models of adolescent self‐mutilation.
Suicide and Life-Threatening Behavior, 33(3), 277–287.
Rothschild, B. (2000). The body remembers. New York: Norton.
Bibliography 181
Ryle, G. (1949). The concept of mind. Chicago: The University of Chicago Press.
Sacks, O. (2012). Hallucinations. New York: Alfred A. Knopf.
Salomon, R., Malach, R., & Lamy, D. (2009). Involvement of the intrinsic/
default system in movement-related self recognition. PLoS One, 4(10), e7527.
Sartre, J.-P. (1956). Being and nothingness (H. Barnes, Trans.). New York:
Philosophical Library.
Sato, A., & Yasuda, A. (2005). Illusion of sense of self-agency: Discrepancy between
the predicted and actual sensory consequences of actions modulates the sense of
self-agency, but not the sense of self-ownership. Cognition, 94(3), 241–255.
Saxe, G. N., Chawla, N., & Van der Kolk, B. A. (2002). Self-destructive behavior
in patients with dissociative disorders. Suicide and Life—Threatening Behavior,
32(3), 313–320.
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.
Sedda, A. (2011). Body integrity identity disorder: From a psychological to a
neurological syndrome. Neuropsychology Review, 21(4), 334–336. https://doi.
org/10.1007/s11065-011-9186-6.
Semprun, J. (1998). Literature or life (L. Coverdale, Trans.). New York: Penguin
Books.
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.
Shalamov, V. T. (1994). Kolyma tales. (J. Glad, Trans.) London: Penguin Books.
Silva, J. A., Leong, G. B., & Weinstock, R. (1993). Delusions of transformation
of the self. Psychopathology, 26(3–4), 181–188.
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.
Spiegel, D. (1997). Trauma, dissociation, and memory. Psychobiology of
Posttraumatic Stress Disorder, 821, 225–237.
Stanley, B., Winchel, R., Molcho, A., Simeon, D., & Stanley, M. (1992).
Suicide and the self-harm continuum: Phenomenological and biochemical
182 Bibliography
evidence. International Review of Psychiatry, 4(2), 149–155. https://doi.

org/10.3109/09540269209066312.
Steinberg, M. (2004). Systematic assessment of posttraumatic dissociation. In
J. P. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD
(pp. 122–143). New York: Guilford Press.
Stovall-McClough, K. C., & Cloitre, M. (2006). Unresolved attachment,
PTSD, and dissociation in women with childhood abuse histories. Journal
org/10.1037/0022-006x.74.2.219.
Stratton, G. M. (1896). Some preliminary experiments on vision without inver-
sion of the retinal image. Psychological Review, 3(6), 611–617.
Sutton, J. (2007). Healing the hurt within (3rd ed.). Hachette, UK: How To
Books.
Swannell, S., Martin, G., Page, A., Hasking, P., Hazell, P., Taylor, A., & Protani,
M. (2012). Child maltreatment, subsequent non-suicidal self-injury and the
mediating roles of dissociation, alexithymia and self-blame. Child Abuse &
Neglect, 36(7), 572–584. https://doi.org/10.1016/j.chiabu.2012.05.005.
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.
Terr, L. C. (1991). Childhood traumas: An outline and overview. Journal of the
American Psychiatric Association, 148(1), 10–20. https://doi.org/10.1176/
foc.1.3.322.
Treat, J. W. (1995). Writing ground zero: Japanese literature and the atomic
bomb. Chicago: University of Chicago Press.
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., Hesse, M. D., Boy, C., Haggard, P., & Fink, G. R. (2006). Neural
signatures of body ownership: A sensory network for bodily self-conscious-
ness. Cerebral Cortex, 17(10), 2235–2244.
Tsakiris, M., Longo, M., & Haggard, P. (2010). Having a body versus
moving your body: Neural signatures of agency and body-ownership.
Neuropsychologia, 48(9), 2740–2749.
Umans, M. (1992). Untitled. The Cutting Edge: A Newsletter for Women Living
with Self-inflicted Violence, 3(3), 7.
Ursano, R. J., Fullerton, C. S., Epstein, R. S., Crowley, B., Vance, K., & Kao,
T. C. (1999). Peritraumatic dissociation and posttraumatic stress disorder fol-
lowing motor vehicle accidents. The American Journal of Psychiatry, 156(11),
1808–1810.
Bibliography 183

533–551. https://doi.org/10.1007/s00221-008-1562-y.
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 Hart, O., Van Dijke, A., Van Son, M., & Steele, K. (2000). Somatoform
dissociation in traumatized World War I combat soldiers: A neglected clinical
heritage. Journal of Trauma and Dissociation, 1(4), 33–66.
Van der Kolk, B. A. (1987). Psycological trauma. Washington, DC: American
Psychiatric Press.
Van der Kolk, B. A. (1994). The body keeps the score: Memory and the evolv-
ing psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1(5),
253–265. https://doi.org/10.3109/10673229409017088.
Van der Kolk, B. A. (2014). The body keeps the score. New York: Viking.
Van der Kolk, B. A., & Fisler, R. (1995). Dissociation and the fragmentary
natureof traumatic memories: Overview and exploratory study. Journal of
Traumatic Stress, 8, 505–525. Retrieved January 11, 2011, from David
Baldwins Trauma Pages. http://www.trauma-pages.com/a/vanderk2.php.
Van der Kolk, B. A., Pelcovitz, D., Roth, S., & Mandel, F. S. (1996).
Dissociation, somatization, and affect dysregulation: The complexity
of adaption to trauma. The American Journal of Psychiatry, 53(Suppl.),
83–93.
self-destructive behavior. American Journal of Psychiatry, 148(12), 1665–
1671. https://doi.org/10.1176/ajp.148.12.1665.
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.
1009–1020.
science and human experience. Cambridge: MIT Press.
Waelde, L. C., Silvern, L., & Fairbank, J. A. (2005). A taxometric investigation
of dissociation in Vietnam veterans. Journal of Traumatic Stress, 18(4), 359–
369. https://doi.org/10.1002/jts.20034.
184 Bibliography
Wakefield, P. L., Frank, A., & Meyers, R. W. (1977). The hobbyist: A euphe-
mism for self-mutilation and fetishism. Bulletin of the Menninger Clinic,
41(6), 539.
Weierich, M. R., & Nock, M. K. (2008). Posttraumatic stress symptoms medi-
ate the relation between childhood sexual abuse and nonsuicidal self-injury.
Journal of Consulting and Clinical Psychology, 76(1), 39–44. https://doi.
org/10.1037/0022-006x.76.1.39.
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.
concog.2011.01.005.
Wolf, E. J., Miller, M. W., Reardon, A. F., Ryabchenko, K. A., Castillo, D.,
& Freund, R. (2012). A latent class analysis of dissociation and post-
traumatic stress disorder: Evidence for a dissociative subtype. Archives
of General Psychiatry, 69(7), 698–705. https://doi.org/10.1001/
archgenpsychiatry.2011.1574.
Yates, T. M. (2004). The developmental psychopathology of self-injurious behav-
ior: Compensatory regulation in posttraumatic adaptation. Clinical Psychology
Review, 24(1), 35–74. https://doi.org/10.1016/j.cpr.2003.10.001.
Yates, T. M. (2009). Developmental pathways from child maltreatment to non-
suicidal self-injury. In M. K. Nock (Ed.), Understanding nonsuicidal self-in-
jury: Origins, assessment, and treatment (pp. 117–137). Washington, DC:
American Psychological Association. https://doi.org/10.1037/11875-007.
Index
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

https://doi.org/10.1057/978-1-349-95366-0
186 Index
-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 dissocia-
tion/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 fight or flight, 86
derealization, 104, 117, 132 first-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 flashbacks, 8, 104, 107, 131, 138
Index 187
flesh, 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,
objectification/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 field, 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 field, 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 confinement, 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

Body Disownership in C-P.t.s.d.

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Body Disownership in C-P.t.s.d.

Uploaded by

Copyright:

Available Formats

B O DY

ISBN 978-1-349-95365-3 ISBN 978-1-349-95366-0 (eBook)

Library of Congress Control Number: 2018937874

© The Editor(s) (if applicable) and The Author(s) 2018

Cover image: © Richard Wareham Fotografie/Alamy Stock Photo

Printed on acid-free paper

What happens at the most negative extremes of torture and trauma?

The analyses provided by Ataria are thus nuanced and complex in

Memphis, USA Shaun Gallagher

In 2014, Shaun Gallagher invited me to attend a conference in Memphis

the following institutions: Berlin School of Mind and Brain, Humboldt

2 The Twofold Structure of Human Beings 13

3.3 Lack of Sense of Ownership Toward the Entire Body 36

4 When Ownership and Agency Collide:

5 The Complex Relations Between SA and SBO During

6 Self-Injuring Behavior 101

6.5 SIB as a Means of Communication 112

7 The Destructive Nature of Complex PTSD 131

Body-Disownership—Concluding Remarks 151

Fig. 3.1 Three levels of the sense of body-ownership 36

Severe and ongoing trauma can result in impairments at the body-

1.1 When the Body Is the Enemy—

© The Author(s) 2018 1

Having clarified these concepts, let us return to the cognitive incon-

Sense of agency (SA) Sense of body-ownership (SBO)

Yet, this first-order contradiction between SBO and SA at the body-

of body-ownership at the body-image level. A similar gap exists between

Second order contradiction First order contradiction

Body-Image Judgment of Judgment of

This double dissociation between body-schema and body-image is

1.3 Trauma—The Collapse of the Knowing-How

To perceive, we require the pre-reflective ability to master our move-

In extreme cases, the collapse of the knowing-how structure may cause

1 Throughout the book, quotations representing first-person subjective experiences are

italicized. In these quotations, boldface font is used to emphasize particular segments.

our ability to predict and possibly distorting our perception. According

was tortured, stays tortured. Torture is ineradicably burned into him”

1.4 Complex Posttraumatic Stress Disorder

experienced as that which ‘stands in the way,’ an obstinate force inter-

1.5 Outline of the Book

part of the chapter examines the meaning of belonging or not-belonging

(POW) conducted according to the phenomenological approach (see

de Vignemont, F. (2017). Mind the body. Oxford: Oxford University Press.

The Twofold Structure of Human Beings

2.1 The Twofold Structure of the Human Body

© The Author(s) 2018 13

Merleau-Ponty believes that the twofold human body constitutes the

In so far as, when I reflect on the essence of subjectivity, I find it bound

The essence of subjectivity can be explained in terms of the first-per-

Yet it would be a mistake to treat the perceptual field as polar and

Tactile experience… adheres to the surface of our body; we cannot unfold

The perceptual field encompasses a combination of subject and object.

2 Merleau-Ponty introduced the concept of flesh late in his writing.

and invades reality. Merleau-Ponty uses the concept of flesh to describe

performance is made explicit and may often be disturbed” (Fuchs &

Essentially, according to Merleau-Ponty, this tension is necessary for our

2.2 Body-Schema and Body-Image

2.2.1 Theory of Body-Schema—Theory of Perception

the “body is inescapably linked with phenomena” (Merleau-Ponty, 2002,

Consider a missile guidance system. When the missile is following an air-

3 As opposed to knowing-that (Ryle, 1949).

2.2.2 Body-Schema Versus Body-Image: Double Dissociation

1. The perceptual experience of one’s own body;

Fig. 3.1 Three levels of the sense of body-ownership 36

1.3 Trauma—The Collapse of the Knowing-How

1.5 Outline of the Book

The Twofold Structure of Human Beings

2.1 The Twofold Structure of the Human Body

2.2 Body-Schema and Body-Image

2.2.1 Theory of Body-Schema—Theory of Perception

1. The perceptual experience of one’s own body;

1. move and act in-the-world automatically, without consciously

3.1 Ownership Versus Sense of Body-Ownership (SBO)

3.3 Lack of Sense of Ownership Toward

Fig. 3.2 The phenomenology of autoscopic experiences. This figure shows the

Fig. 3.3 Flexibility of the sense of body-ownership. Schematic and simplified

Fig. 3.4 Body-as-subject vs. body-as-object. Points A–D on the curve in Fig. 3.3

1. Activated at the body-schema level;

When Ownership and Agency Collide:

4.3 Towards a Theory of Limb-Disownership

4.3.1.1 Somatoparaphrenia—Beyond a Lack of SBO

4.3.1.3 Somatoparaphrenia: A Full-Blown Conflict