FOREWORD What happens at the most negative extremes of torture and trauma? What happens to our bodies and to our selves? Yochai Ataria, in BodyDisownership 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 experience 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 phenomenological difference between the body-as-subject or lived-body (Leib) and the body-as-object (Körper) is a basic distinction informing Ataria’s analysis. 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 parallel, 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 symbol “≈,” 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 phenomenologically or neurologically. In terms of neuroscience, both experiences depend upon sensory integration processes (some of which are likely correlated 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 moving, but I am not the agent of that movement (in such cases, no efferent 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 complicated, 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 central 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 perceptual, 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 unusual 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 reality (this is the important work of Olaf Blanke and colleagues). But this is just what Ataria does. He shows the resemblances of these phenomena, 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 perplexing 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 intersubjective. 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 conference. 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 comments. 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 contribution of the various comments made during these seminars and conferences 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 crucial 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 When the Body Is the Enemy—Améry’s Basic Intuition 1.2 Disownership 1.3 Trauma—The Collapse of the Knowing-How Structure 1.4 Complex Posttraumatic Stress Disorder 1.5 Outline of the Book References 1 1 2 5 8 9 11 2 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 2.2.2 Body-Schema Versus Body-Image: Double Dissociation 2.2.3 Nothing Is Within Our Reach 2.3 What Not-Belonging Feels Like References 13 13 17 17 Ownership 3.1 Ownership Versus Sense of Body-Ownership (SBO) 3.2 SBO—Manipulations 3.2.1 The Rubber Hand Illusion 3.2.2 Prosthetic Limbs 29 29 30 31 31 3 19 22 23 26 xv xvi CONTENTS 3.3 Lack of Sense of Ownership Toward the Entire Body 3.3.1 Autoscopic Phenomena 3.3.2 Minimal Phenomenal Selfhood (MPS) 3.3.3 Total Lack of Sense of Ownership Toward the Entire Body 3.4 SBO—Main Insights References 4 5 6 When Ownership and Agency Collide: The Phenomenology of Limb-Disownership 4.1 Sense of Agency 4.2 Ownership vs. Agency: Double Dissociation 4.3 Towards a Theory of Limb-Disownership 4.3.1 Somatoparaphrenia 4.3.2 Body Integrity Identity Disorder (BIID) 4.3.3 Some Insights Concerning Limb-Disownership References The Complex Relations Between SA and SBO During Trauma and the Development of Body-Disownership 5.1 Dissociation—A Defense Mechanism Activated During Trauma 5.2 Weakening of the SBO During Trauma 5.3 Loss of SA 5.4 The Relations Between SBO and SA During Trauma 5.5 The Development of Body-Disownership 5.5.1 Body-Disownership—What Does It Feel Like References Self-Injuring Behavior 6.1 Self-Injuring Behavior: A Brief Introduction 6.2 Self-Injuring Behavior as a Coping Mechanism 6.3 SIB: A Long-Term Reaction to Severe Trauma 6.4 SIB and Traumatic Memories 6.4.1 The Nature of the Traumatic Memory 6.4.2 SIB as a Coping Mechanism for Traumatic Memories 36 37 41 44 49 49 53 53 55 58 59 66 74 75 81 81 82 85 87 90 91 97 101 101 103 105 106 106 108 CONTENTS SIB as a Means of Communication 6.5.1 Bodily Trauma and the Need for a New Language 6.5.2 No One Believes 6.5.3 Breaking the Silence 6.6 SIB as a Tool for Managing Dissociation 6.7 The Phenomenology of SIB 6.7.1 SIB at the Body-Schema Level: Being-in-a-Hostile-World 6.7.2 SIB at Body-Image Level: The Body-for-Itself-for-Others 6.7.3 SIB: Body-Image Versus Body-Schema References 112 112 114 114 117 121 The Destructive Nature of Complex PTSD 7.1 The Complex Nature of PTSD 7.2 C-PTSD from a Phenomenological Perspective 7.3 Structural Dissociation 7.4 Toward an Understanding of Body-Disownership 7.5 Toward a Cognitive Model of Body-Disownership References 131 131 134 137 142 144 146 6.5 7 xvii 121 122 124 126 Body-Disownership—Concluding Remarks 151 Appendices 155 Bibliography 167 Index 185 LIST OF FIGURES Fig. 3.1 Fig. 3.2 Fig. 3.3 Fig. 3.4 Fig. 6.1 Fig. 7.1 Fig. 7.2 Three levels of the sense of body-ownership The phenomenology of autoscopic experiences Flexibility of the sense of body-ownership Body-as-subject vs. body-as-object Trade-off between dissociation and self-injuring behavior The deadly outcomes of trauma type II Sense of body-ownership that is too strong 36 37 48 48 121 143 145 xix BOOK ABSTRACT Severe and ongoing trauma can result in impairments at the bodyschema 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 suffering: “When the whole body is filled with pain, we try to get rid of the © The Author(s) 2018 Y. Ataria, Body Disownership in Complex Posttraumatic Stress Disorder, https://doi.org/10.1057/978-1-349-95366-0_1 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 phenomenological levels and to demonstrate that this mechanism is responsible 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 “bodyimage 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 organisational processes (body-schema) with (b) higher order, top-down bodily 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 bodyas-object (body-image). 1 INTRODUCTION Leib Körper First-person perspective (1PP) Third-person perspective (3PP) Body-as-subject Body-as-object Body-schema Body-image 3 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 artificial. This book uses terms such as Leib, 1PP, body-as-subject and body-schema somewhat synonymously 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 phenomenological world, while body-image is more cognitive Having clarified these concepts, let us return to the cognitive incongruities 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 contradiction 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 bodyschema level is insufficient for limb-disownership to develop. Rather, a second-order contradiction is also necessary. To understand this second-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 (bodyschema) 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 contradiction alone is not sufficient for limb-disownership to occur. Body-Schema Ownership Agency Feeling of ownership Feeling of agency First order contradiction Second order contradiction Body-Image Judgment of ownership Judgment of 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 mechanisms are detached from one another does not mean they do not engage in dialogue. Indeed, they work together on a regular basis; their synchronization 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 perspectives, according to which the mind, the body, and the world are considered 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 bodyschema 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 physical 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 character of input” (O’Regan & Noë, 2001, p. 84). 6 Y. ATARIA To perceive, we require the pre-reflective ability to master our movements 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 knowledge is damaged, rendering us incapable of tuning into sensorimotor contingencies 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 knowledge. 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 certain 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 structure. Our ability to remain systematically tuned into our environment based on a set of laws or sensorimotor contingencies enables us to perceive. Hence, damage to this sensorimotor circuit weakens our ability to perceive. In perceptual terms, though only in perceptual terms, we may compare 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 wearing 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 knowinghow 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 construct a new system connecting between expectations and actual possible outcomes, thus modifying the knowing-how structure. In the long term, however, the outcomes can be devastating because the very structure of the sensorimotor loops has become embedded within trauma. Considering this in terms of someone who cannot see the world without 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 individual cannot remove the inverting glasses. The implications of this notion are far-reaching: Traumatic experiences can cause changes at the bodyschema 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 particular (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 prisons, 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 simple PTSD but victims of ongoing trauma at times also develop characteristic 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 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” (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 interfering 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 bodyimage (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 chapter further focuses on the discrepancy between body-schema and bodyimage. 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 completely 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 phenomena. In addition, it examines the phenomenology of depersonalization 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 investigation 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 second-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 feelings 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 possible 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 z 1. As in the cases of somatoparaphrenia and BIID, this can result in limb-disownership. The same mechanism may be activated with respect to the whole body. Indeed, Améry’s (1980) description of his feelings while being tortured reveals the phenomenology 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 argument 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 mechanism 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.