7. Self-awareness: This aspect of the self is almost axiomatic; a self that is not aware of itself is an oxymoron. Later in this chapter I will argue that your self-awareness might partly depend on your brain using mirror neurons recursively, allowing you to see yourself from another person’s (allocentric) viewpoint. Hence the use of terms like “self-conscious” (embarrassed), when what you really mean is being conscious of someone else being conscious of you.
These seven aspects, like the legs of a table, work together to hold up what we call the self. However, as you can already see, they are vulnerable to illusions, delusions, and disorders. The table of the self can continue to stand without one of these legs, but if too many are lost then its stability becomes severely compromised.
How did these multiple attributes of self emerge in evolution? What parts of the brain are involved, and what are the underlying neural mechanisms? There are no simple answers to these questions—certainly nothing to rival the simplicity of a statement like “because that is how God made us”—but just because the answers are complicated and counterintuitive is no reason to give up the quest. By exploring several syndromes that straddle the boundary between psychiatry and neurology, I believe we can glean invaluable clues to how the self is created and sustained in normal brains. In this regard my approach is similar to that used elsewhere in the book: considering odd cases to illuminate normal function.5 I do not claim to have “solved” the problem of self (I wish!), but I believe these cases provide very promising ways it can be approached. Overall, I think this is not a bad start for tackling a problem that is not even considered legitimate by many scientists.
Several points are worth noting before we examine particular cases. One is that despite the bizarreness of symptoms, each patient is relatively normal in other respects. A second is that each patient is completely sincere and confident in his belief and this belief is immune from intellectual correction (just like persistent superstitions in otherwise rational people). A patient with panic attacks might agree with you intellectually that his forebodings of doom are not “real,” but during the attack itself, nothing will convince him that he isn’t dying.
One last caveat: We need to be careful when drawing insights from psychiatric syndromes because some of them (none, I hope, that I am examining here) are bogus. Take for example de Clérambault syndrome, which is defined as a young woman developing an obsessive delusion that a much older and famous man is madly in love with her but he is in denial about it. Google it if you don’t believe me. (Ironically there’s no name for the very real and common delusion in which an older gentleman believes that a young hottie is in love with him but doesn’t know it! One reason for this might be that the psychiatrists who “discover” and name syndromes have historically been men.)
Then there is Koro, the alleged disorder said to afflict Asian gentlemen who claim that their penis is shrinking and will eventually wither away. (Again the converse does exist in some elderly Caucasian men—the delusion that the penis is expanding—when it actually isn’t. This was pointed out to me by my colleague Stuart Anstis.) Koro is likely to have been fabricated by Western psychiatrists, though it is not inconceivable that it might arise from a reduced representation of the penis in the body-image center, the right superior parietal lobule.
And let’s not forget another notable invention, “oppositional defiant disorder.” This diagnosis is sometimes given to smart, spirited youngsters who dare to question the authority of older establishment figures, such as psychiatrists. (Believe it or not, this is a diagnosis for which a psychologist can actually bill the patient’s insurance company.) The person who concocted this syndrome, whoever he or she is, is brilliant, for any attempt by the patient to challenge or protest the diagnosis can itself be construed as evidence for its validity! Irrefutability is built into its very definition. Another pseudomalady, again officially recognized, is “chronic under-achievement syndrome”—what used to be called stupidity.
With these caveats in mind let us try to tackle the syndromes themselves and explore their relevance to the self and to human uniqueness.
Embodiment
We will begin with three disorders that allow us to examine the mechanisms involved in creating a sense of embodiment. These conditions reveal that the brain has an innate body image, and when that body image doesn’t match up with the sensory input from the body—whether visual or somatic—the ensuing disharmony can disrupt the self’s sense of unity as well.
APOTEMNOPHILIA: DOCTOR, REMOVE MY ARM PLEASE
Vital to the human sense of self is a person’s feeling of inhabiting his own body and owning his body parts. Although a cat has an implicit body image of sorts (it doesn’t try to squeeze into a rat hole), it can’t go on a diet seeing that it is obese or contemplate its paw and wish it weren’t there. Yet the latter is precisely what happens in some patients who develop apotemnophilia, a curious disorder in which a completely normal individual has an intense and ever-present desire to amputate an arm or a leg. (“Apotemnophila” derives from the Greek: apo, “away from” temnein, “to cut” and philia, “emotional attachment to.”) He may describe his body as being “overcomplete” or his arm as being “intrusive.” You get the feeling that the subject is trying to convey something ineffable. For instance he might say, “It’s not as if I feel it doesn’t belong to me, Doctor. On the contrary, it feels like it’s too present.” More than half the patients go on to actually have the limb removed.
Apotemnophilia is often viewed as being “psychological.” It has even been suggested that it arises from a Freudian wish-fulfillment fantasy, the stump resembling a large penis. Others have regarded the condition as attention-seeking behavior, although why the desire for attention should take this strange form and why so many of these people keep their desires secret for much of their lives is never explained.
Frankly, I find these psychological explanations unconvincing. The condition usually begins early in life, and it is unlikely that a ten-year-old would desire a giant penis (although an orthodox Freudian wouldn’t rule it out). Moreover, the subject can point to the specific line—say, two centimeters above the elbow—along which she desires amputation. It isn’t simply a vague desire to eliminate a limb, as one would expect from a psychodynamic account. Nor can it be a desire to attract attention, for if that were the case, why be so particular about where the cut should be made? Finally, the subject usually has no other psychological issues of any consequence.
There are also two other observations I made of these patients that strongly suggest a neurological origin for the condition. First, in more than two-thirds of cases the left limb is involved. This disproportionate involvement of the left arm reminds me of the decidedly neurological disorder of somatoparaphrenia (described later), in which the patient, who has a right-hemisphere stroke, not only denies the paralysis of his left arm but also insists that the arm doesn’t belong to him. This is rarely seen in those with left-hemisphere strokes. Second, my students Paul McGeoch and David Brang and I have found that touching the limb below the line of the desired amputation produces a big jolt in the patient’s GSR (galvanic skin response), but touching above the line or touching the other limb does not. The patient’s alarm bells really and truly go off when the affected limb is touched below the line. Since it’s hard to fake a GSR, we can be fairly sure of a neurological basis for the disorder.