Cognitive Neuropsychiatry (201800819)
Utrecht University 2023-2024
Articles in this summary:
● Bekrater-Bodmann, R., et al. (2016). Body plasticity in borderline personality disorder: A link
to dissociation. Comprehensive Psychiatry, 69, 36-44.
● Blom, R.M., Hennekam, R.C., Denys, D. (2012). Body integrity identity disorder. PlosOne, 7,
e34702.
● Stone, K. D., Kornblad, C. A. E., Engel, M. M., Dijkerman, H. C., Blom, R. M., & Keizer, A.
(2020). An Investigation of Lower Limb Representations Underlying Vision, Touch, and
Proprioception in Body Integrity Identity Disorder. Frontiers in Psychiatry, 11, 15.
https://doi.org/10.3389/fpsyt.2020.00015
● Lynn, S. J., Maxwell, R., Merckelbach, H., Lilienfeld, S. O., Kloet, D. V. H., & Miskovic, V. (2019).
Dissociation and its disorders: Competing models, future directions, and a way forward.
Clinical psychology review, 73, 101755.
● Huntjens, R.J.C., Rijkeboer, M.M. & Arntz, A. (2019). Schema therapy for Dissociative Identity
Disorder (DID): rationale and study protocol, European Journal of Psychotraumatology, 10:1.
● Van Rooij, et al (2015). Predicting treatment outcome in PTSD: A longitudinal functional MRI
study on trauma-unrelated emotional processing. Neuropsychopharmacology
● Eekhout et al (2016) Post-traumatic stress symptoms 5 years after military deployment to
Afghanistan: an observational cohort study. Lancet Psychiatry
● Sommer IEC, Koops S, Blom JD. (2012). Comparison of auditory hallucinations across
different disorders and syndromes. Neuropsychiatry; 2, 57-68.
● Daalman, K; Boks, MP; Diederen, KMP; de Weijer, AD; Blom, JD; Kahn, RS; Sommer, IEC
(2011). The Same or Different? A Phenomenological Comparison of Auditory Verbal
Hallucinations in Healthy and Psychotic Individuals. The Journal of clinical psychiatry; 72(3),
18878.
● Begemann MJ, Sommer IE, Brand RM, Oomen PP, Jongeneel A, Berkhout J, Molenaar RE,
Wielage NN, Toh WL, Rossell SL, Bell IH (2022). Auditory verbal hallucinations and childhood
trauma subtypes across the psychosis continuum: a cluster analysis. Cognitive
Neuropsychiatry;27(2-3):150-68.
● Blair, R.J. (2013). The neurobiology of psychopathic traits in youths. Nature Reviews
Neuroscience, 14, 11, 786-799.
● Rijders, RJP, Terburg,D., Bos, PA, Kempes, MM, Van Honk, J. (2021). Unzipping empathy in
psychopathy: Empathy and facial affect processing in psychopaths. Neuroscience &
Biobehavioural reviews, 131, 1116-1126.
● Engel, M.M. & Keizer, A. (2018). Body representation disturbances in visual perception and
affordance perception persist in eating disorder patients after completing treatment.
Scientific Reports, 7, article number 16184.
● Gadsby, S. (2021). Visual self-misperception in eating disorders. Perception, 50(11), 933-949.
1
,HC1: Body plasticity in borderline personality disorder: A link to dissociation
The perception of ownership for one's body, i.e., the sensation that the whole body or its parts
belong to oneself, is an essential feature of self-experience. As a result of the integration of
body-related sensory input, a coherent experience of the body is generated, forming the base of
one's own corporeal identity.
The rubber hand illusion (RHI) offers a tool to experimentally manipulate the experience of the body.
In this paradigm, the sensation of ownership for an artificial limb is induced through visuotactile
stimulation of the artificial limb in synchrony with the participant's real but hidden limb. Thus, the
RHI represents a multisensory phenomenon probing one's body plasticity, which describes how fluid
people perceive the borders of their own body and how much they can incorporate objects from the
peripersonal environment.
Both body acceptance and body perception have been shown to be distorted in borderline
personality disorder, which is further characterized by emotional dysregulation, disturbed
interpersonal relationships, and impaired self-awareness. In addition, dissociation is common in BPD.
Dissociation refers to a detachment from the immediate surroundings or emotional and physical
experiences, including the feeling that one's body does not belong to oneself. These perceptual
features suggest that dissociation might be related to a higher level of body plasticity. It has been
suggested that dissociation might be a coping mechanisms related to overly strong emotions.
We found that subjects with current BPD compared to HC were significantly more prone to perceive
ownership for an artificial limb. This alteration was specific for patients with current BPD, indicating
that a remission is accompanied by a normalization of body plasticity. Further, when we controlled
for symptom severity, we found a significant positive relationship between both state (in the
moment) and trait (stable) dissociation and illusory limb ownership sensations, which was
non-significant in the case of trait dissociation when symptom severity was not considered. We
conclude that dissociation as clinical feature is positively associated with body plasticity in BPD.
There is extensive evidence that BPD is accompanied by reduced pain perception. However, this
sensory alteration appears to be specific for the pain domain, as patients with BPD show no
alterations in tactile and proprioceptive perception compared to healthy controls. This is of special
importance in the light of the present results, since the sensation of body ownership relies on the
capability to relate seen and felt touch and posture and thus multisensory integration, which is
different from perception in one modality.
The current BPD group responded more strongly than both control groups on a subjective level (in
the experimental condition when congruent
stimulation was applied). The
non-significant differences in perceiving
congruence between seen and felt touch
indicate that basic multisensory integration
capabilities are intact, suggesting that
top-down rather than bottom-up processing
is altered in BPD.
2
,Most importantly, the results presented here not only indicate enhanced body plasticity in current
BPD, but its relationship to dissociation. These results clearly suggest that naturally occurring
dissociation is related to higher degrees of body plasticity, probably complicating the differentiation
between oneself and the environment. This perceptual alteration might explain certain symptoms in
BPD patients such as uncertainties related to one's own identity and experiences of
depersonalization.
Our findings may also be related to neurochemical alterations in BPD. Healthy participants reported
stronger sensations of illusory limb ownership in the RHI paradigm after a dose of ketamine
compared to a placebo. Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist inducing
dissociation. So, dysfunctions related to the NMDA neurotransmission might at least partly
contribute to the enhanced body plasticity in BPD. It is suggested that the effect of ketamine on the
RHI by central changes allowing the integration of an artificial body part into one's body
representation. Our results indicate that naturally occurring dissociation, which actually represents a
central phenomenon, may be based on similar neurobiological and psychological mechanisms.
Although we did not find a significantly enhanced proprioceptive drift (i.e. the tendency to locate
one's own limb as closer to the artificial limb after successful RHI induction) in the current BPD
group, there was a characteristic enhancement in this measure. Further, the proprioceptive drift was
significantly correlated with induced illusory limb ownership in the current BPD subgroup, but it was
not associated with dissociation, indicating a dissociation-specific enhancement of subjective body
plasticity.
A widely distributed frontoparietal network, is involved in higher-order body perception. Reduced
own body ownership experiences have been shown to be related to dysfunctions in this network
involved in the integration of somatosensory, vestibular, and visual input, such as the premotor
cortex, posterior parietal cortex, and cerebellum. Furthermore, the temporoparietal junction is
involved in maintaining a coherent body perception. Dysfunction of the TPJ is related to dissociative
body experiences. Our findings suggest alterations in this or other integrative areas in BPD.
As a consequence of enhanced body plasticity, BPD patients might be unable to stabilize
self-awareness and related concepts, such as sexual identity and the self-image.
HC2: Body integrity identity disorder
Body Integrity Identity Disorder (BIID) is a rare condition in which persons typically report an intense
desire either to be paralyzed or to have one or more of their healthy limbs to be amputated. Some
researchers have proposed to broaden the intended use of BIID to refer to individuals with a
persistent desire to acquire a physical disability.
BIID is not a paraphilia nor does the desire to amputate the limb reflect psychosis amputation.
Rather it is believed that BIID is an identity disorder. The main motivation for the preferred body
modification is believed to be a mismatch between actual and perceived body schema. The
symptoms of BIID parallel those in somatoparaphrenia, a syndrome occurring secondary to right
3
, parietal lobe damage by a cerebral tumor or stroke. This similarity, coupled with the early onset,
suggests that BIID could be a congenital disorder. Het staat momenteel niet in de ICD of de DSM.
Discussion
BIID has an onset in early childhood; 80% are men. Main rationale given for their desire for body
modification is to feel complete or to feel satisfied inside, sexual motives are often secondary. In the
present study the main reasons reported for body modification in all subjects were to feel whole,
complete, set right again or to feel satisfied inside, none of the subjects had primary sexual motives.
However 25 (46.3%) subjects felt sexually aroused when seeing someone disabled resembling their
BIID and 24 (44.4%) felt sexually aroused when imagining themselves being disabled. Possibly the
sexual component in BIID is often one of feeling sexually more comfortable with one’s body.
Prevalence rates of homosexual and bisexual orientation are high.
Emotional distress
Somatic and severe psychiatric comorbidity is unusual, but depressive symptoms and mood disorders
can be present, possibly secondary to the enormous distress BIID puts upon a person. BIID influences
lives of affected subjects in all facets in an extreme way. Obsessions with BIID are present every day,
many individuals spent time pretending, using crutches, bandage their limbs or using a wheelchair.
BIID individuals disclose their BIID to their family and friends in just half of the cases.
Surgery
Subjects that underwent amputation score significantly lower on a disability scale than BIID subjects
who did not undergo body modification, suggesting that surgery does offer benefits to subjects. BIID
individuals prefer being in harmony with one’s identity, even if it results in physical disability. Surgery
appears to result in permanent remission of BIID and in impressive improvement of quality of life,
but conflicts with ethical standards of physicians indicating not to amputate healthy limbs.
Variations
Since there are no clear differences in any other parameter between the amputation and
paralyzation BIID variants, we consider these as the same condition. We hypothesize that amputation
of the body part affected in the paralyzation variant would usually lead to incompatibility with life if
it would be amputated and therefore people (unconsciously) prefer to be paralyzed. Alternatively,
individuals with the paralyzation variant may specifically seek to be paralyzed as such.
Not part of psychosis
One of the BIID individuals was schizophrenic, however her BIID thoughts were not considered as
part of a psychosis. On the other hand, amputation due to psychosis is known to occur but is not
considered to be BIID since the motivation for amputation is often delusional like ‘‘performing
mission for God’’.
Neurology
The aetiology of BIID remains unclear. Congenital abnormal body representation in the brain has
been proposed. Time of onset (usually from as early as BIID individuals can remember), similarities
with somatophrenia, and persisting exactness of line of wished amputation are arguments for such a
deficit. The preliminary finding of absence of activity in the right superior parietal lobule when
4
