Still Life: Psychological transformations in a Quadriplegia case

(Publicado en Revista Chilena de Neuropsicologia, 2011)

Berlin, 2011, Neuropsychoanalysis Congress

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What is Quadriplegia?

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What is the relevance of exploring psychological changes in quadriplegia?

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to neuro-rehabilitation?

• Increase in number of cases and longer life expectancy.

• There is no clear understanding of the clinical profile of this subpopulation.

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to Neuropsychoanalysis?

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? ?

Subjective experience; Complex psychological processes CNS

this is not a new idea!

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“If you were to cut all the nerves that bring brain signals to the body proper, your body state would change radically, and so consequently would your mind. Were you to cut only the signals from the body proper to the brain, your mind would change too. Even partial blocking of brain-body traffic, as happens in patients with spinal cord injury, causes changes in mind state”

(A. Damasio, 1994, Descartes’ Error, p. 227, )

but….which are these changes in mind state?

• Three clinical observations:

• Physical immobility (Still Life) appears to be related to introversion of psychical energy.

• A decoupling between “virtual” and “physical” body may occur.

• Changes in the emotional body geography can take place.

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The case of Mrs A

• C6 lesion secondary to tumour resection.

• 53 years

• Divorced, 23yrs son.

• Hospitalized 1mth after lesion

• 14mth as inpatient

• Mechanical ventilation

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Physical immobility (Still Life) generates an introversion of psychical energy.

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Pie

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Cla

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Physical immobility (Still life) and introversion of psychical energy

• Total physical dependence.

• “Effortful” existence eat talk breath

• low metabolism, (Mollinger et al., 1985)

• Decrease on bodily-Self / environment interactions (Agency)

• Withdrawal of attention from non-novel environment.

“What do you do with these patients? they are constantly sleeping!

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Physical immobility (Still life) and

introversion of psychical energy

• Sleep and (day) dreaming:

• Experience: an equilibrium of internally and externally driven activity.

• Hyper-activation of imagination (internally “driven”)

• Could this decrease on organism-environment interaction be associated to complex “psychological” changes?

• Cognitive changes and quadriplegia (Richards & Melamed, 1982)

• Grey matter volume changes on body-representation areas after peripheral autonomic denervation (Critchley et al., 2003)

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Four Hands: Decoupling between “virtual” and “physical” body

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• Mrs A: the stones on my hands are bothering me • CS: which ones? (looking at her hands resting on top of her stomach) • Mrs A: not those ones. The ones that are lying by the side of my body. • CS: how? • Mrs A: that is the crazy thing. That I feel my hands in a place where I

know they are not. • CS: and if you close your eyes, can you think about moving those

hands? • Mrs A: no • CS: how about the other hands, the ones you can see. How do they

feel like? • Mrs A: I don’t feel them • CS: and how do you know they are yours? • Mrs A: I don’t know. Maybe by looking at them I know they are mine. • CS: let’s do something. Could you close your eyes, please? How are

your hands now? • Mrs A: they are at the side of my body, holding the stones. • CS: what about the other pair of hands, the ones that you would see if

you open your eyes… do you feel them? • Mrs A: no.

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Where is my real body? Feeling and knowing

• Changes in the body experience have been scarcely described (virtual/physical body)

• Reduplication of extremities on quadriplegia (Ohry &

Zeilig, 1989)

• Supernumerary phantom limb after stroke (Halligan &

Marshall, 1995; Halligan et al., 1993; McGonogle et al., 2002; Miyazawa et al., 2004; Srivastava et al., 2008)

• Sensory-motor map is transformed after amputation (Chen et al., 2002; Giumarra et al., 2007, Clarke et al., 1996,

Ramachandran et al., 1992)

• These changes generate high levels of Anxiety.

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Where does your sadness end? Changes on the emotional body geography

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• CS: do you feel like your emotions have changed after your spinal cord lesion? I mean the way that you feel them or experience them?

• Mrs A: frankly I haven’t noticed anything different. I think that I’m still the same person.

• CS: do you mean, for example, that when you feel sad now, the way you feel it is the same as before?

• Mrs A: yep, I think so. • CS: could you describe me how you feel your body when you feel sad

now? • Mrs A: oh! Sadness does not go further that point (looks at the

imaginary line in her chest that divides her body) • CS: how? • Mrs A: that’s right. I feel sadness up to that point… till the point I feel

my body. From there below I don’t feel. • CS: what do you feel below that line? • Mrs A: I could not say is sadness. Sometimes don’t feel anything.

Sometimes have sensations, as if was feeling parts of my stomach. I know is my body, and that I’m stuck to it, but I don’t feel it. At least as something clear.

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Quadriplegia and changes on emotional body geography

• Quadriplegia and affective neuroscience

• Changes in emotional life after quadriplegia:

• Intensity (Chwalisz et al., 1988; Hohmann, 1966; Montoya Schandry, 1994)

• Affective value and experiencing different emotions (Cobos et al.,

• 2002; Cobos et al., 2004)

• How much body do we need to experience emotions?

• Hormonal routes and face nerves (North & O’Carroll, 2001)

• As if loop (Dunn et al., 2006)

• Mrs A could experience all the range of emotions and intensities

• Retraction in the body limits of the self.

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Concluding remarks

• Subjective experience after acquiring quadriplegia need to be further explored in order to comprehend the diverse challenges that adapting to such lesions imply.

• Emotional changes may not be only related to body-brain traffic interruption, but also to changes in how organism and environment interact.

• Quadriplegia cases must be considered as belonging to the neuropathologies of the self (Salas & Turnbull, 2011)

• These clinical observations are anecdotal evidence.

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Gracias!

www.rehabilitacionneuropsicologica.com