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The importance of body experience for psychiatry
The Importance of Body Experience for Psychiatry 2. J. Lipowski HE REALM OF SUBJECTIVE body experience in health and disease is an indispensable, although neglected, dimension of psychiatric knowledge and practice. By body experience I mean the perceptions of, attitudes towards, and beliefs about one’s own body appearance and functions. Body experience is changed in all forms of psychopathology and it contributes one of the psychopathogenic factors in physical illness, injury, and disability. Paul Schilder, who pioneered the study of body experience, summed it up succinctly: “Organic disease and psychogenic disturbance lead in the same way to suffering. Suffering expresses itself necessarily in the postural model of the body. Mental suffering finds its way into a somatic expression, and somatic disease leads to mental suffering.” ’ The key theoretical concept in this area is that of the body image. Schilder defined it as the “tri-dimensional image everybody has about himself.” Recent writers, notably Fisher* and Shontz,3 have elaborated this concept and reviewed the massive literature on experimental work related to it. I shall describe examples of these studies and discuss the importance of this whole area for psychiatry.
T
CLARIFICATION
OF KEY TERMS
Research on body experience falls into two major categories: perception and personality. 3 Perceptual research stems from the work of Henry Head on what he called body schema.4 This concept connotes a plastic model which everybody builds up from his somatic perceptions. Its function is to provide a standard for and a guiding influence upon the posture and spatial orientation of the body. Any change in the position of the body is related to the postural schema, which allows automatic judgment of the change and appropriate adjustment of the body to it. Head’s work stimulated a large volume of clinical, especially neurologic, and experimental perceptual studies using the construct of body schema. Disorders of body awareness, for example unawareness and denial of left hemiplegia, led to a search for cerebral localization of the body schema. Neurologic case studies resulted in the hypothesis that disorders of body experience, such as anosognosia, are due to damage to parietal lobe of the nondominant, i.e., usually right, cerebral hemisphere. More recent work indicates that both parietal lobes as well as the sensorimotor cortex, the parieto-occipital area, and the temporal lobe all participate in the elaboration of body awareness.3 Personality research on body experience is of much greater interest for psychiatrists. It has employed the concept of body image, a psychological and not a physiological construct, in contrast to body schema. This research continues the original approach of Paul Schilder,’ who acknowledged the physiological basis of the body image but expanded the concept by adding to it a psychologic and social From the Department of Psychiatry. Dartmouth MedicalSchool, Hanover, New Hampshire. Z. J. Lipowski, M.D.: Professor of Psychiatry, Dartmouth Medical School, Hanover, New Hampshire. Reprint requests should be addressed to Dr. 2. J. Lipowski, Professor of Psychiatry, Dartmouth MedicalSchool. Hanover, N.H. 03755. 0 1977 by Grune & Slratlon. Inc. AWN 0010-440X. Comprehensive Psychiatry.Vol. 18. No. 5 (September/October),
1977
473
474
Z. J. LIPOWSKI
connotation. He regarded the body image as closely linked with personality in that it both reflects individual personality traits and influences them. Psychological factors, such as emotions, conflicts, defenses, fantasies, etc., affect a person’s body image and experience. Body parts and functions are invested with conscious and unconscious symbolic meanings which influence a person’s attitude towards his own body and the bodies of others as well as his reactions to perceived changes in the appearance and functions of the body. Body image is modified by actual injury to the body, say by loss of a limb, and thus mediates psychological and psychopathological responses to physical illness and injury. Personality-oriented research on body experience is focused on discovering correlations between various measures of personality and the characteristics of subjective body perception. These studies are not concerned with the accuracy and constancy of the perception of the size and other objective characteristics of one’s own body. Their goal is to investigate how a subject experiences his or her body as a value-laden psychological object.” SOME RECENT RESEARCH
ON BODY IMAGE
Fisher and Cleveland’ have introduced a methodologically fertile concept of the body image boundary. They proposed that an important dimension of the body image is the manner in which a person experiences the limits of his body. People vary in regard to their perception of their body boundaries as firm, definite, protective against external intrusion, and differentiating them from their surroundings. Normally, the perception of one’s body boundaries is unconscious and allows a sense of firm demarcation from the external world. In pathological states, such as cerebral disease or schizophrenia, there may be blurring of the experienced body boundaries and confusion as to which events occur within or without the physical limits of one’s body. The finiteness of perceived body boundaries in both health and disease may be studied by projective tests, such as Rorschach or Holtzman blots. Fisher and Cleveland developed a scoring method of the perceived boundaries of the ink blots. They categorized the relevant responses into two broad classes which they used as a basis for two separate scores: the barrier responses and the penetration responses, respectively. Responses to the blots stressing finiteness of boundaries comprise the Barrier score. Responses expressed in terms of the weakness, indefiniteness, and penetrability of the boundaries are quantified as Penetration score. Application of the boundary scores in clinical research produced some interesting results. For example, patients suffering from neuro-dermatitis, rheumatoid arthritis, and conversion symptoms involving voluntary musculature displayed higher Barrier and lower Penetration scores than patients with gastric ulcer and spastic colitis. A hypothesis was validated that persons with different body boundary perception develop under stress different symptoms and dysfunction. Subjects with high Barrier scores tend to develop disorders and complaints related to skin and muscles. By contrast, subjects with high Penetration scores develop symptoms and dysfunction involving interior of the body, such as the stomach, intestine, etc. Persons with definite boundaries and thus a high Barrier score are better able to cope with stress and physical disability. For example, patients recovering from poliomyelitis adjusted better to their disability if they had a high Barrier score.2
BODY EXPERIENCE
475
Another dimension of the body image is body awareness.2 There are wide differences in the degree of it. Some people tend to disregard somatic perceptions and minimize their potentially threatening significance. Others are highly attuned to the messages from the body and respond to external information to the extent that bodily feelings are aroused by it. Fisher has quantified body awareness with a score called Body Prominence, which he derived from a subject’s responses to a directive to list “20 things that you are aware of or conscious of right now.” All references to the body and its functions contribute to the person’s Body Prominence score. Heightened body awareness characterizes hypochondriacal persons who attend selectively to bodily sensations and tend to view them as threatening. Another investigative tool is the Body Focus Questionnaire.2 It contains 108 items divided into eight scales related to front-back, right-left, heart, stomach, eyes, mouth, head, and arms. The subject is asked to pick one of each of 108 pairs of body parts of which he is currently more aware, e.g., head or stomach, eyes or hair, right ear or left ear, etc. A score for each of the eight scales is equal to the number of times it (e.g. back or head) is chosen as being more clearly in awareness. Every person tends to focus on certain parts of his or her body and disregard other parts. Each major body area acquires a special value and symbolic meaning for the person. Such meaning tends to be unconscious, to reflect intrapsychic conflicts and defenses, and to signify an interest in and/or a tendency to avoid certain kinds of experience. Conflicts may relate to incorporation, elimination, sexual or hostile impulses and activities, drive for power, and closeness to others. In men, for example, eyes are found to be associated with themes of incorporation, of taking in objects from the environment. Men also tend to equate the right side of the body with masculinity. These symbolic meanings appear to be determined in part by childhood experiences. If people important to the child give special importance to a body part or function by stressing its value, complaining of symptoms related to it, or displaying interest in it in the child, the latter develops associative links between the body part on the one hand and specific attitudes, emotions and behavior, on the other. For example, if the mother complains of a headache every time she appears to be angry, the child may learn to associate the head with expression and control of anger and hostility.” Symbolic meanings of body parts and functions are important for clinicians for at least two reasons. First, conflicts and impulses are often accompanied by somatic perceptions which become symbolically associated with them. These perceptions may be interpreted by the person as signifying disease and thus lead to a medical consultation. The perceptions are then presented as bodily complaints. And second, disorder of a body part or function often activates symbolic meanings associated with it and leads to emotional overreaction and irrational attitudes and behavior. This is one of the psychopathogenic mechanisms which may be triggered by even mild and transient physical illness or injury. It accounts for some of the idiosyncratic and pathological behavioral responses to organic disorders. Researchers have attempted to correlate awareness of particular parts and organs of the body with psychological variables. Heart awareness in men, for example, has been found to be associated with religiosity, dedication to work, and concern about guilt.2 This finding indicates that patients who report symptoms reflecting enhanced perception of cardiac activity share psychological characteris-
476
2. J. LIPOWSKI
tics which can help identify pathogenic conflicts. Men with high mouth and stomach awareness are reported to be selectively concerned and conflicted about anger and aggression in themselves and others.’ They tend to view themselves as vulnerable to attack from outside. Mouth and stomach awareness in women tends to be associated with wishes and conflicts concerning power. Head awareness in women was found to be related to conflicts over heterosexual impulses. Such heightened sensitivity to her head could represent a woman’s unconscious tendency to avoid awareness of sexual stimuli2 An interesting projective method for the study of body experience has been devised by Cassell.” It consists of a set of twelve pictures having anatomical connotations referring to body organs and systems. This technique has been used to investigate individual sensitivity to stimuli emanating from various areas of the body. Such differential sensitivity influences a person’s tendency to respond with specific somatic symptoms to psychosocial stress, to react with alarm or indifference to perceptions related to pathology, and hence to seek, delay, or avoid medical consultation and adoption of the sick role. Cassell has provided a promising method for the study of somatic symptoms occurring in the absence of detectable organic pathology. He postulates that such symptoms, for example pain, occur when the person feels threatened by a social situation or event and his more complex mental defense mechanisms fail to protect him against unpleasant arousal. The person then becomes more aware of his body and is apt to develop an unconscious fantasy of a threat of bodily assault. The presence of this fantasy may be inferred from his responses to the anatomical cards. A different approach to the study of the body image has been used by Plutchik and his coworkers.” They constructed nine paper-and-pencil tests designed to study satisfaction with, preferred proportions and boundaries of the body. One of the tests elicits and quantifies body worries and discomforts. They were found to be more common among women and commonest in schizophrenics. The head, the eyes, the stomach, and the back are the most frequently complained of areas. There is no relation between age and the number and frequency of bodily discomforts and worries. Aging as such does not lead to disturbance, distortion, or regression of one’s body image. On the other hand, special life experiences and situations, such as those subsumed under the terms psychosocial stress or mental illness, increase the incidence of body image disorders expressed as bodily discomforts and worries. Emotional arousal in response to a stressful social situation or event tends to enhance the awareness of commonplace innocuous symptoms and facilitate their interpretation as a threat. Such appraisal is in turn influenced by one’s knowledge and beliefs about disease, and by social and cultural variables.’ Furthermore, longitudinal studies have shown that fear of bodily harm seems to be a consistent trait of a person from early childhood on. Boys who displayed anxiety about physical harm during preschool years tended to show body anxiety and anxiety about sexuality as adults.’ Other studies have focused on the value which people attach to various body parts.“. 10.I I Large samples of people of various ages and socioeconomic status have been asked which body parts they would miss most if they lost them. In one study the leg, the eye, and the arm were considered most important. This finding held regardless of age. Men placed a greater dollar value on their body parts than did women. Psychiatric patients, regardless of age, placed significantly less value on their bodies than did subjects without psychiatric problems.g In another study
477
BODY EXPERIENCE
about 1000 men and 1000 women were asked to rank 12 bodily parts according to the degree with which their removal would be missed.” Socioeconomic status had no effect on the responses. Men ranked the penis, the testicles, and the tongue highest. This ranking was invariant over age, except that the elderly subjects attached lower rank to the sex organs. Women up to the age of 70 ranked the tongue first. These studies suggest certain commonalities in people’s attitudes towards their bodies within a culture. Responses to disease, however, are modified by idiosyncratic subjective meanings which the affected body part or function has for a given person.‘2 The intensity of emotional reactions to bodily disease or mutilation correlates not with the severity of pathology but with the subjective meaning and value, conscious and unconscious, of the diseased or lost organ or function.13 This brief sampling of recent research on body experience offers but a glimpse of the topics being investigated and the techniques used. The latter include projective tests, drawings, distorting mirrors, aniseikonic lenses, tachistoscopically presented pictures of distorted bodies, word association, attitude questionnaires, and manipulation of bodily perceptions with false sensory feedback. IMPORTANCE
OF BODY EXPERIENCE FOR PSYCHIATRY
There are several cogent reasons why research on and knowledge about subjective body experience in health and illness are relevant for psychiatric practice and training. I shall discuss them briefly. Perception and Labeling of Bodily Changes Codetermine
Emotional Behavior
The work of Schachter and Singer,14 Valins,15 and others shows that emotional states are jointly determined by the perception and labeling of bodily changes.15 Perception of such changes, concomitant with a state of physiological arousal, leads the person to try and explain their meaning. Cognitive appraisal and emotional labeling of the perceived bodily changes depend on the person’s immediate social situation and past experience. Thus, peripheral bodily changes trigger cognitive processes which affect our subjective and behavioral responses to external stimuli. Failure to label and/or utilize internal bodily cues is said to contribute to disorders like psychopathy, overeating, and obesity. 15*16 Perception of peripheral bodily changes concomitant with emotional arousal may intensify the emotional state. For example, awareness of overbreathing or tachycardia associated with anxiety tends to enhance the latter by virtue of the cognitive appraisal of the somatic symptoms in terms of threat. Treatment with psychotropic drugs, various relaxation techniques, and biofeedback aims at elimination of such positive feedback. Another relevant aspect of emotions is that their language is always tied to body processes.” Recent studies have shown that as children grow older they are increasingly apt to report stimulating conditions of the emotion as being within themselves. Girls tend to associate feelings, such as anger or sadness, with visceral body sensations. Boys are more likely to internalize their emotions in the head and brain.” Younger children describe their emotions as bodily sensations; older ones describe them more as ideas or thoughts. Developmental, cultural, and psychological factors appear to determine the persistence of and regression to the use of body language for emotional states. This linguistic habit influences the ways in which emotions are communicated in clinical settings.‘*
478
Stress-Related
2. J. LIPOWSKI
Emotional Arousal Leads to Somatic S_vmptoms
Social stress induces emotional arousal which often gives rise to perception of bodily changes. Such perception may be interpreted by the person as a sign of illness and communicated as somatic complaints. Social, medical, and economic consequences of such illness behavior are immense. For example, a study of 4000 consecutive new patients admitted to the medical clinic of a Canadian teaching hospital showed that 30% of them had an emotional disorder believed to be relevant to the presenting symptoms.‘” Somatic mode of perception and communication of emotional arousal and distress leads to overutilization of health care and its high cost. Faulty diagnosis and management of patients, and unwarranted adoption and perpetuation of the sick role are common consequences. Psychiatrists should play a key role in prevention, early identification, and proper management of the somatizing patients.‘” Physical Illness. Body Experience,
and Psychopatholog)
Physical illness and injury as well as mutilating surgery change the person’s body image and experience. The subjective meaning of such a change in terms of loss or threat is one of the psychopathogenic mechanisms responsible for the 20% to 50% concurrence of physical and psychiatric disorders.” Early assessment of a patient’s changed body experience and its personal meaning for him are needed if psychological decompensation and deviant illness behavior are to be prevented. Changed Body Experience
Accompanies
and Enhances Psychopatholog??
Intrapsychic and interpersonal conflicts are common sources of unpleasant emotional arousal and changed body experience. Every psychiatric disorder involves dysphoric emotions and concomitant perception of bodily changes. Depression, schizophrenia, anxiety neurosis, conversion hysteria, and hypochondriasis are the most common psychiatric disorders accompanied by changed somatic perceptions and disorders of the body image.2’,‘L2 The changed experience of the body may lead to the development of somatic symptoms. Such symptoms have a positive feedback effect on dysphoric emotions and psychopathology. They may be given unconscious symbolic meaning resulting in secondary and tertiary symptoms. They lead to attempts at relief which may be the start of new psychiatric problems, be it alcoholism, drug addiction, or polysurgery. At times they lead to chronic patienthood with primary and secondary gains for the patient. Timely therapy aimed at relief of unpleasant body experience concomitant with emotional distress may help relieve the latter and prevent the complications. It seems desirable to teach children to label and communicate their emotions in psychological terms. Such education could help check the current tendency to define problems in living as ill-health. No wonder that the cost of health care in this country is estimated to be $115 billion a year, i.e., 8% of the GNP.*” Pleasurable Bodv Experience:
A Goal
of Therap?>
Enhancement of pleasurable body experience is a goal of all therapies. Inadequate hedonic capacity is one of the commonest focused on helping people to seek treatment. 2a Specific techniques modify their body experience in the course of psychoanalytically psychotherapy have been developed. 2s They try to make the patient
psychiatric reasons for patients to oriented aware of his
BODY EXPERIENCE
479
or her facial expression, posture, movements, and breathing, and to encourage changes in them during therapeutic sessions. This approach aims deliberately at increased capacity for pleasurable body experience. CONCLUSIONS
Body experience helps determine the quality of life and reflects sensitively physiological functioning and psychosocial stress. It is influenced by emotional stimuli and in turn modifies emotional states. It is a potentially psychopathogenic factor in physical illness and injury, and influences illness behavior. Its knowledge is indispensable for psychiatrists and should be part of their training. Rotation on a liaison service provides a foremost opportunity to teach this aspect of psychobiology since disturbances of body experience are complained of by every patient the consultant sees. REFERENCES I. Schilder P: Image and Appearance of the Human Body. New York, International Universities, 1950 2. Fisher S: Body Experience in Fantasy and Behavior. New York, Appleton-Century-Crofts, 1970 3. Shontz FC: Perceptual and Cognitive Aspects of Body Experience. New York, Academic Press, 1969 4. Head H: Studies in Neurology, vol 2. London, Oxford University, 1920 5. Cassell WA: Individual differences in somatic perception: A projective methods of investigation, in Lipowski ZJ (ed): Psychosocial Aspects of Physical Illness. Basel, Karger, 1972, ~~86-104 6. Plutchik R, Weiner BM, Conte H: Studies of body image. I. Body worries and body discomforts. J Gerontology 26:344350, 1971 7. Mechanic D: Social psychologic factors affecting the presentation of bodily complaints. N Engl J Med 286:1132~1139, 1972 8. Kagan J, Moss HA: Birth to Maturity. New York, Wiley, 1962 9. Plutchik R, Conte H, Weiner BM: Studies of body image. II. Dollar values of body parts. J Gerontology 28:89-91, 1973 10. Gorman W: Body Image and the Image of the Brain. St. Louis, W.H. Green, 1969 11. Weinstein S, Semen EA, Fisher L, et al: Preferences for bodily parts as a function of sex, age, and socioeconomic status. Am J Psycho1 77:29lI294, 1964 12. Lipowski ZJ: Physical illness, the patient and his environment: Psychosocial foundations of medicine, in Arieti S, Reiser MF (eds): American Handbook of Psychiatry, ed 2, vol 4. New York, Basic Books, 1975, pp 3-42 13. Shontz FC: The Psychological Aspects of
Physical Illness and Disability. New York, Macmillan, 1975 14. Schachter S, Singer JE: Cognitive, social, and physiological determinants of emotional state. Psycho1 Rev 69:379-399, 1962 15. Valins S: The perception and labeling of bodily changes as determinants of emotional behavior, in Black P (ed): Physiological Correlates of Emotion. New York, Academic, 1970, pp 229-243 16. Schachter S: Cognitive effects on bodily functioning: Studies of obesity and eating, in Glass D (ed): Neurophysiology and Emotion. New York, Rockefeller University, 1967, pp 91-97 17. Lewis WC, Wolman RN, King M: The development of the language of emotions. Am J Psychiatry 127:1491-1497, 1971 18. Spaulding WB: The psychosomatic approach in the practice of medicine. Int J Psychiatr Med6:169-181, 1975 19. Lowy FH: Management of the persistent somatizer. Int J Psychiatr Med 6:227-239, 1975 20. Lipowski ZJ: Psychiatry of somatic diseases: Epidemiology, pathogenesis, classification. Compr Psychiatry 16:1055124, 1975 21. Shontz FC: Body image and its disorders. Int J Psychiatr Med 5:461l472, 1974 22. Kolb LC: Disturbances of the body-image, in Arieti S, Reiser MF (eds): American Handbook of Psychiatry, ed 2, vol 4. New York, Basic Books, 1975, pp 8 IO-837 23. Thomas L: The health care system. N Engl J Med 293:124551246, 1975 24. Meehl PE: Hedonic capacity: Some conjectures. Bull Menninger Clin 39:2955307, 1975 25. Kinston M, Wolff H: Bodily communication and psychotherapy: A psychosomatic approach. Int J Psychiatr Med 6:195-201, 1975
T
CLARIFICATION
OF KEY TERMS
Research on body experience falls into two major categories: perception and personality. 3 Perceptual research stems from the work of Henry Head on what he called body schema.4 This concept connotes a plastic model which everybody builds up from his somatic perceptions. Its function is to provide a standard for and a guiding influence upon the posture and spatial orientation of the body. Any change in the position of the body is related to the postural schema, which allows automatic judgment of the change and appropriate adjustment of the body to it. Head’s work stimulated a large volume of clinical, especially neurologic, and experimental perceptual studies using the construct of body schema. Disorders of body awareness, for example unawareness and denial of left hemiplegia, led to a search for cerebral localization of the body schema. Neurologic case studies resulted in the hypothesis that disorders of body experience, such as anosognosia, are due to damage to parietal lobe of the nondominant, i.e., usually right, cerebral hemisphere. More recent work indicates that both parietal lobes as well as the sensorimotor cortex, the parieto-occipital area, and the temporal lobe all participate in the elaboration of body awareness.3 Personality research on body experience is of much greater interest for psychiatrists. It has employed the concept of body image, a psychological and not a physiological construct, in contrast to body schema. This research continues the original approach of Paul Schilder,’ who acknowledged the physiological basis of the body image but expanded the concept by adding to it a psychologic and social From the Department of Psychiatry. Dartmouth MedicalSchool, Hanover, New Hampshire. Z. J. Lipowski, M.D.: Professor of Psychiatry, Dartmouth Medical School, Hanover, New Hampshire. Reprint requests should be addressed to Dr. 2. J. Lipowski, Professor of Psychiatry, Dartmouth MedicalSchool. Hanover, N.H. 03755. 0 1977 by Grune & Slratlon. Inc. AWN 0010-440X. Comprehensive Psychiatry.Vol. 18. No. 5 (September/October),
1977
473
474
Z. J. LIPOWSKI
connotation. He regarded the body image as closely linked with personality in that it both reflects individual personality traits and influences them. Psychological factors, such as emotions, conflicts, defenses, fantasies, etc., affect a person’s body image and experience. Body parts and functions are invested with conscious and unconscious symbolic meanings which influence a person’s attitude towards his own body and the bodies of others as well as his reactions to perceived changes in the appearance and functions of the body. Body image is modified by actual injury to the body, say by loss of a limb, and thus mediates psychological and psychopathological responses to physical illness and injury. Personality-oriented research on body experience is focused on discovering correlations between various measures of personality and the characteristics of subjective body perception. These studies are not concerned with the accuracy and constancy of the perception of the size and other objective characteristics of one’s own body. Their goal is to investigate how a subject experiences his or her body as a value-laden psychological object.” SOME RECENT RESEARCH
ON BODY IMAGE
Fisher and Cleveland’ have introduced a methodologically fertile concept of the body image boundary. They proposed that an important dimension of the body image is the manner in which a person experiences the limits of his body. People vary in regard to their perception of their body boundaries as firm, definite, protective against external intrusion, and differentiating them from their surroundings. Normally, the perception of one’s body boundaries is unconscious and allows a sense of firm demarcation from the external world. In pathological states, such as cerebral disease or schizophrenia, there may be blurring of the experienced body boundaries and confusion as to which events occur within or without the physical limits of one’s body. The finiteness of perceived body boundaries in both health and disease may be studied by projective tests, such as Rorschach or Holtzman blots. Fisher and Cleveland developed a scoring method of the perceived boundaries of the ink blots. They categorized the relevant responses into two broad classes which they used as a basis for two separate scores: the barrier responses and the penetration responses, respectively. Responses to the blots stressing finiteness of boundaries comprise the Barrier score. Responses expressed in terms of the weakness, indefiniteness, and penetrability of the boundaries are quantified as Penetration score. Application of the boundary scores in clinical research produced some interesting results. For example, patients suffering from neuro-dermatitis, rheumatoid arthritis, and conversion symptoms involving voluntary musculature displayed higher Barrier and lower Penetration scores than patients with gastric ulcer and spastic colitis. A hypothesis was validated that persons with different body boundary perception develop under stress different symptoms and dysfunction. Subjects with high Barrier scores tend to develop disorders and complaints related to skin and muscles. By contrast, subjects with high Penetration scores develop symptoms and dysfunction involving interior of the body, such as the stomach, intestine, etc. Persons with definite boundaries and thus a high Barrier score are better able to cope with stress and physical disability. For example, patients recovering from poliomyelitis adjusted better to their disability if they had a high Barrier score.2
BODY EXPERIENCE
475
Another dimension of the body image is body awareness.2 There are wide differences in the degree of it. Some people tend to disregard somatic perceptions and minimize their potentially threatening significance. Others are highly attuned to the messages from the body and respond to external information to the extent that bodily feelings are aroused by it. Fisher has quantified body awareness with a score called Body Prominence, which he derived from a subject’s responses to a directive to list “20 things that you are aware of or conscious of right now.” All references to the body and its functions contribute to the person’s Body Prominence score. Heightened body awareness characterizes hypochondriacal persons who attend selectively to bodily sensations and tend to view them as threatening. Another investigative tool is the Body Focus Questionnaire.2 It contains 108 items divided into eight scales related to front-back, right-left, heart, stomach, eyes, mouth, head, and arms. The subject is asked to pick one of each of 108 pairs of body parts of which he is currently more aware, e.g., head or stomach, eyes or hair, right ear or left ear, etc. A score for each of the eight scales is equal to the number of times it (e.g. back or head) is chosen as being more clearly in awareness. Every person tends to focus on certain parts of his or her body and disregard other parts. Each major body area acquires a special value and symbolic meaning for the person. Such meaning tends to be unconscious, to reflect intrapsychic conflicts and defenses, and to signify an interest in and/or a tendency to avoid certain kinds of experience. Conflicts may relate to incorporation, elimination, sexual or hostile impulses and activities, drive for power, and closeness to others. In men, for example, eyes are found to be associated with themes of incorporation, of taking in objects from the environment. Men also tend to equate the right side of the body with masculinity. These symbolic meanings appear to be determined in part by childhood experiences. If people important to the child give special importance to a body part or function by stressing its value, complaining of symptoms related to it, or displaying interest in it in the child, the latter develops associative links between the body part on the one hand and specific attitudes, emotions and behavior, on the other. For example, if the mother complains of a headache every time she appears to be angry, the child may learn to associate the head with expression and control of anger and hostility.” Symbolic meanings of body parts and functions are important for clinicians for at least two reasons. First, conflicts and impulses are often accompanied by somatic perceptions which become symbolically associated with them. These perceptions may be interpreted by the person as signifying disease and thus lead to a medical consultation. The perceptions are then presented as bodily complaints. And second, disorder of a body part or function often activates symbolic meanings associated with it and leads to emotional overreaction and irrational attitudes and behavior. This is one of the psychopathogenic mechanisms which may be triggered by even mild and transient physical illness or injury. It accounts for some of the idiosyncratic and pathological behavioral responses to organic disorders. Researchers have attempted to correlate awareness of particular parts and organs of the body with psychological variables. Heart awareness in men, for example, has been found to be associated with religiosity, dedication to work, and concern about guilt.2 This finding indicates that patients who report symptoms reflecting enhanced perception of cardiac activity share psychological characteris-
476
2. J. LIPOWSKI
tics which can help identify pathogenic conflicts. Men with high mouth and stomach awareness are reported to be selectively concerned and conflicted about anger and aggression in themselves and others.’ They tend to view themselves as vulnerable to attack from outside. Mouth and stomach awareness in women tends to be associated with wishes and conflicts concerning power. Head awareness in women was found to be related to conflicts over heterosexual impulses. Such heightened sensitivity to her head could represent a woman’s unconscious tendency to avoid awareness of sexual stimuli2 An interesting projective method for the study of body experience has been devised by Cassell.” It consists of a set of twelve pictures having anatomical connotations referring to body organs and systems. This technique has been used to investigate individual sensitivity to stimuli emanating from various areas of the body. Such differential sensitivity influences a person’s tendency to respond with specific somatic symptoms to psychosocial stress, to react with alarm or indifference to perceptions related to pathology, and hence to seek, delay, or avoid medical consultation and adoption of the sick role. Cassell has provided a promising method for the study of somatic symptoms occurring in the absence of detectable organic pathology. He postulates that such symptoms, for example pain, occur when the person feels threatened by a social situation or event and his more complex mental defense mechanisms fail to protect him against unpleasant arousal. The person then becomes more aware of his body and is apt to develop an unconscious fantasy of a threat of bodily assault. The presence of this fantasy may be inferred from his responses to the anatomical cards. A different approach to the study of the body image has been used by Plutchik and his coworkers.” They constructed nine paper-and-pencil tests designed to study satisfaction with, preferred proportions and boundaries of the body. One of the tests elicits and quantifies body worries and discomforts. They were found to be more common among women and commonest in schizophrenics. The head, the eyes, the stomach, and the back are the most frequently complained of areas. There is no relation between age and the number and frequency of bodily discomforts and worries. Aging as such does not lead to disturbance, distortion, or regression of one’s body image. On the other hand, special life experiences and situations, such as those subsumed under the terms psychosocial stress or mental illness, increase the incidence of body image disorders expressed as bodily discomforts and worries. Emotional arousal in response to a stressful social situation or event tends to enhance the awareness of commonplace innocuous symptoms and facilitate their interpretation as a threat. Such appraisal is in turn influenced by one’s knowledge and beliefs about disease, and by social and cultural variables.’ Furthermore, longitudinal studies have shown that fear of bodily harm seems to be a consistent trait of a person from early childhood on. Boys who displayed anxiety about physical harm during preschool years tended to show body anxiety and anxiety about sexuality as adults.’ Other studies have focused on the value which people attach to various body parts.“. 10.I I Large samples of people of various ages and socioeconomic status have been asked which body parts they would miss most if they lost them. In one study the leg, the eye, and the arm were considered most important. This finding held regardless of age. Men placed a greater dollar value on their body parts than did women. Psychiatric patients, regardless of age, placed significantly less value on their bodies than did subjects without psychiatric problems.g In another study
477
BODY EXPERIENCE
about 1000 men and 1000 women were asked to rank 12 bodily parts according to the degree with which their removal would be missed.” Socioeconomic status had no effect on the responses. Men ranked the penis, the testicles, and the tongue highest. This ranking was invariant over age, except that the elderly subjects attached lower rank to the sex organs. Women up to the age of 70 ranked the tongue first. These studies suggest certain commonalities in people’s attitudes towards their bodies within a culture. Responses to disease, however, are modified by idiosyncratic subjective meanings which the affected body part or function has for a given person.‘2 The intensity of emotional reactions to bodily disease or mutilation correlates not with the severity of pathology but with the subjective meaning and value, conscious and unconscious, of the diseased or lost organ or function.13 This brief sampling of recent research on body experience offers but a glimpse of the topics being investigated and the techniques used. The latter include projective tests, drawings, distorting mirrors, aniseikonic lenses, tachistoscopically presented pictures of distorted bodies, word association, attitude questionnaires, and manipulation of bodily perceptions with false sensory feedback. IMPORTANCE
OF BODY EXPERIENCE FOR PSYCHIATRY
There are several cogent reasons why research on and knowledge about subjective body experience in health and illness are relevant for psychiatric practice and training. I shall discuss them briefly. Perception and Labeling of Bodily Changes Codetermine
Emotional Behavior
The work of Schachter and Singer,14 Valins,15 and others shows that emotional states are jointly determined by the perception and labeling of bodily changes.15 Perception of such changes, concomitant with a state of physiological arousal, leads the person to try and explain their meaning. Cognitive appraisal and emotional labeling of the perceived bodily changes depend on the person’s immediate social situation and past experience. Thus, peripheral bodily changes trigger cognitive processes which affect our subjective and behavioral responses to external stimuli. Failure to label and/or utilize internal bodily cues is said to contribute to disorders like psychopathy, overeating, and obesity. 15*16 Perception of peripheral bodily changes concomitant with emotional arousal may intensify the emotional state. For example, awareness of overbreathing or tachycardia associated with anxiety tends to enhance the latter by virtue of the cognitive appraisal of the somatic symptoms in terms of threat. Treatment with psychotropic drugs, various relaxation techniques, and biofeedback aims at elimination of such positive feedback. Another relevant aspect of emotions is that their language is always tied to body processes.” Recent studies have shown that as children grow older they are increasingly apt to report stimulating conditions of the emotion as being within themselves. Girls tend to associate feelings, such as anger or sadness, with visceral body sensations. Boys are more likely to internalize their emotions in the head and brain.” Younger children describe their emotions as bodily sensations; older ones describe them more as ideas or thoughts. Developmental, cultural, and psychological factors appear to determine the persistence of and regression to the use of body language for emotional states. This linguistic habit influences the ways in which emotions are communicated in clinical settings.‘*
478
Stress-Related
2. J. LIPOWSKI
Emotional Arousal Leads to Somatic S_vmptoms
Social stress induces emotional arousal which often gives rise to perception of bodily changes. Such perception may be interpreted by the person as a sign of illness and communicated as somatic complaints. Social, medical, and economic consequences of such illness behavior are immense. For example, a study of 4000 consecutive new patients admitted to the medical clinic of a Canadian teaching hospital showed that 30% of them had an emotional disorder believed to be relevant to the presenting symptoms.‘” Somatic mode of perception and communication of emotional arousal and distress leads to overutilization of health care and its high cost. Faulty diagnosis and management of patients, and unwarranted adoption and perpetuation of the sick role are common consequences. Psychiatrists should play a key role in prevention, early identification, and proper management of the somatizing patients.‘” Physical Illness. Body Experience,
and Psychopatholog)
Physical illness and injury as well as mutilating surgery change the person’s body image and experience. The subjective meaning of such a change in terms of loss or threat is one of the psychopathogenic mechanisms responsible for the 20% to 50% concurrence of physical and psychiatric disorders.” Early assessment of a patient’s changed body experience and its personal meaning for him are needed if psychological decompensation and deviant illness behavior are to be prevented. Changed Body Experience
Accompanies
and Enhances Psychopatholog??
Intrapsychic and interpersonal conflicts are common sources of unpleasant emotional arousal and changed body experience. Every psychiatric disorder involves dysphoric emotions and concomitant perception of bodily changes. Depression, schizophrenia, anxiety neurosis, conversion hysteria, and hypochondriasis are the most common psychiatric disorders accompanied by changed somatic perceptions and disorders of the body image.2’,‘L2 The changed experience of the body may lead to the development of somatic symptoms. Such symptoms have a positive feedback effect on dysphoric emotions and psychopathology. They may be given unconscious symbolic meaning resulting in secondary and tertiary symptoms. They lead to attempts at relief which may be the start of new psychiatric problems, be it alcoholism, drug addiction, or polysurgery. At times they lead to chronic patienthood with primary and secondary gains for the patient. Timely therapy aimed at relief of unpleasant body experience concomitant with emotional distress may help relieve the latter and prevent the complications. It seems desirable to teach children to label and communicate their emotions in psychological terms. Such education could help check the current tendency to define problems in living as ill-health. No wonder that the cost of health care in this country is estimated to be $115 billion a year, i.e., 8% of the GNP.*” Pleasurable Bodv Experience:
A Goal
of Therap?>
Enhancement of pleasurable body experience is a goal of all therapies. Inadequate hedonic capacity is one of the commonest focused on helping people to seek treatment. 2a Specific techniques modify their body experience in the course of psychoanalytically psychotherapy have been developed. 2s They try to make the patient
psychiatric reasons for patients to oriented aware of his
BODY EXPERIENCE
479
or her facial expression, posture, movements, and breathing, and to encourage changes in them during therapeutic sessions. This approach aims deliberately at increased capacity for pleasurable body experience. CONCLUSIONS
Body experience helps determine the quality of life and reflects sensitively physiological functioning and psychosocial stress. It is influenced by emotional stimuli and in turn modifies emotional states. It is a potentially psychopathogenic factor in physical illness and injury, and influences illness behavior. Its knowledge is indispensable for psychiatrists and should be part of their training. Rotation on a liaison service provides a foremost opportunity to teach this aspect of psychobiology since disturbances of body experience are complained of by every patient the consultant sees. REFERENCES I. Schilder P: Image and Appearance of the Human Body. New York, International Universities, 1950 2. Fisher S: Body Experience in Fantasy and Behavior. New York, Appleton-Century-Crofts, 1970 3. Shontz FC: Perceptual and Cognitive Aspects of Body Experience. New York, Academic Press, 1969 4. Head H: Studies in Neurology, vol 2. London, Oxford University, 1920 5. Cassell WA: Individual differences in somatic perception: A projective methods of investigation, in Lipowski ZJ (ed): Psychosocial Aspects of Physical Illness. Basel, Karger, 1972, ~~86-104 6. Plutchik R, Weiner BM, Conte H: Studies of body image. I. Body worries and body discomforts. J Gerontology 26:344350, 1971 7. Mechanic D: Social psychologic factors affecting the presentation of bodily complaints. N Engl J Med 286:1132~1139, 1972 8. Kagan J, Moss HA: Birth to Maturity. New York, Wiley, 1962 9. Plutchik R, Conte H, Weiner BM: Studies of body image. II. Dollar values of body parts. J Gerontology 28:89-91, 1973 10. Gorman W: Body Image and the Image of the Brain. St. Louis, W.H. Green, 1969 11. Weinstein S, Semen EA, Fisher L, et al: Preferences for bodily parts as a function of sex, age, and socioeconomic status. Am J Psycho1 77:29lI294, 1964 12. Lipowski ZJ: Physical illness, the patient and his environment: Psychosocial foundations of medicine, in Arieti S, Reiser MF (eds): American Handbook of Psychiatry, ed 2, vol 4. New York, Basic Books, 1975, pp 3-42 13. Shontz FC: The Psychological Aspects of
Physical Illness and Disability. New York, Macmillan, 1975 14. Schachter S, Singer JE: Cognitive, social, and physiological determinants of emotional state. Psycho1 Rev 69:379-399, 1962 15. Valins S: The perception and labeling of bodily changes as determinants of emotional behavior, in Black P (ed): Physiological Correlates of Emotion. New York, Academic, 1970, pp 229-243 16. Schachter S: Cognitive effects on bodily functioning: Studies of obesity and eating, in Glass D (ed): Neurophysiology and Emotion. New York, Rockefeller University, 1967, pp 91-97 17. Lewis WC, Wolman RN, King M: The development of the language of emotions. Am J Psychiatry 127:1491-1497, 1971 18. Spaulding WB: The psychosomatic approach in the practice of medicine. Int J Psychiatr Med6:169-181, 1975 19. Lowy FH: Management of the persistent somatizer. Int J Psychiatr Med 6:227-239, 1975 20. Lipowski ZJ: Psychiatry of somatic diseases: Epidemiology, pathogenesis, classification. Compr Psychiatry 16:1055124, 1975 21. Shontz FC: Body image and its disorders. Int J Psychiatr Med 5:461l472, 1974 22. Kolb LC: Disturbances of the body-image, in Arieti S, Reiser MF (eds): American Handbook of Psychiatry, ed 2, vol 4. New York, Basic Books, 1975, pp 8 IO-837 23. Thomas L: The health care system. N Engl J Med 293:124551246, 1975 24. Meehl PE: Hedonic capacity: Some conjectures. Bull Menninger Clin 39:2955307, 1975 25. Kinston M, Wolff H: Bodily communication and psychotherapy: A psychosomatic approach. Int J Psychiatr Med 6:195-201, 1975