Physical Pain Stops my Pain - Treating Teen Self Mutilation

Body perception is a large part of identity formation, and many factors contribute to a person's image of his or her own body. Saturated by images of youthful, seemingly perfect professional models and their lithe bodies, few individuals, especially women, do not experience some sort of dissatisfaction at some time or another with their physical being. An abbreviated survey of the history of fashion shows a long tradition of changing the appearance of the body according to culturally sanctioned standards of beauty. The inflictions humans have endured (and still endure) to appear more alluring and acceptable range from simple and temporary, to humiliating and permanently deforming. A brief list might include shaving, tweezing, dyeing, bleaching, wearing false teeth, false eyelashes, high heels, corsets, and hobble skirts, cicatrisation (scarification), tattooing, skull shaping, and foot binding, not to mention surgical reconstruction of the body.

Describing the body as the oldest artistic medium, Bernard Rudofsky points out that mankind is the only species that has the desire to alter his body. Rudofsky attributes this to a vain desire to look better and prime the ego. Humans wish to transcend the imperfection of nature, which "demands more than artistry or resemblance; in fact resemblance may be the last thing kind] wants. To shore up his ego, he needs an icon, a holy picture of his inner self. Only a faultlessly constructed mask will meet his need-and his approval."49 Striving to adorn and improve nature proposes the human creative and spiritual superiority to animals. Religion serves a similar function. This explains why so many acts of body alteration have magical and spiritual connotations.

Although Rudofsky does not address the physical consequences of body alteration, he does consider various physical and psychological functions of clothing. He theorizes that clothing is not only a mentally and spiritually satisfying method of transforming, or at least masking, the self, but that clothing is a form of self-touch. Apart from protection from environmental hazards, clothing provides tactile pleasure: warmth, softness, comforting constriction, and other forms of autoeroticism. The physical and emotional pleasures of adornment are "narcissistic and exhibitionist pleasures." The same is true for body alteration as a form of self-touch. A discussion of narcissism will illuminate how "self-touch" may be imbued with emotional, magical, and spiritual meaning.

Pathological narcissism is called a disorder of the self because narcissistic individuals have so much difficulty distinguishing the boundaries between themselves and the external world that they are unable to maintain a firm notion of identity. Because narcissistic individuals lack a cohesive self, they are incessantly struggling to create and confirm an identity and a sense of continuity by relating to "self-objects" that mirror themselves and confirm their self-worth. These self-objects may be other people, or they may be physical objects that the narcissist manipulates to secure a psychological and physical confirmation of existence. Because one of the ways in which a child forms a sense of self as a whole and separate entity is by being held and handled, skin contact is an essential part of recognizing boundaries of the self and interacting with the external world. Without sufficient handling and sensory stimulation a child may grow up to have low self-esteem and a distorted body image. Such an individual may learn to use his or her body and its physical sensations as a solacing, "transitional object," an object that replaces the childhood caretaker's task of confirming a bounded self apart from an external world.

Although I have used the term disorder it is important to recognize the ambiguity of this term. Physical being is important to all individuals, especially during certain developmental stages or times of pleasure or sickness, and at one time or another we all comfort ourselves with certain foods, clothing, music, or even smells that reinstate psychological stability by providing physical pleasure. As Heinz Kohut says, "integrity of the body self is a prevalent content of the nuclear self."52 Adolescents typically view the body as a transitional object for a period during their development, but narcissistic individuals experience difficulty moving beyond this stage. This is typical of individuals with eating disorders who often have a distorted image of their bodies.

The narcissist simultaneously seeks to "be self" and paradoxically "not to be self." The narcissist wants his or her existence confirmed, but simultaneously wants to escape the dreadful pain of being an individual alone and unconnected to any other being in the cosmos. The narcissistic anxiety and fear of disintegration can only be eased by identifying with, subsuming, and being subsumed by, an Other. This overbearing, unhealthy desire for an unreachable and perfect unity is an exaggeration of a very normal human desire for something stable and predictable. In some instances, if this stability is not provided by a family or community milieu, an individual may depend upon private rituals for security, or learn that he or she can only find solace in predictable physical stimuli. The searching individual may find comfort in ritualized sadomasochistic interactions or an attachment to a self-object, such as his or her body.

Narcissists both reject and cherish their bodies. "The corruptible aspects of the body-illness, aging, and death-frighten the narcissist." The narcissistic attempts to surmount the limitations of the body in order to deny change and mortality. Because extreme narcissists so desperately desire something they can trust, they believe that the "ego should be above the body's natural fate, it should be unchanging, indestructible, and deathless." Physical sensation may become unusually meaningful for an individual with a disorder of the self and may be manifested in an acute sensitivity to skin eroticism, including both painful and pleasurable sensations. "For an individual without a distinct body image or with a regressive fragmentation of the self, pain can be a means of creating a feeling of aliveness and realness. The receipt of pain establishes or reestablishes a boundary-an experience of existing as a bounded, contained entity."56 To feel is to be. Many of the actions discussed here are painful methods of creating or reestablishing a sense of self.

Individuals with a fragmented sense of self confirm and delineate their body boundaries (and therefore the boundaries of their psychological self) by various forms of skin and body stimulation. They may obsessively wear particular kinds of clothes to feel the material and sensation of rubbing, cut or maim their skin, or compulsively engage in sex. Bingeing, vomiting, and using laxatives or diuretics also cause physical body sensations that shock the body.57 Even exercise may be a pathological expression of the need to feel bounded. "The frenetic pace of excruciating exercise, running, and swimming characteristic of the anorectic may appear to be for the purpose of losing weight, but it is actually a desperate attempt to experience the reality of their bodies, for which they do not have an accurate or distinct mental representation. It is also an effort (as is controlled eating, or of vomiting) at countering the anguish of internal emptiness, boredom, and deadness."58

If, as Philip Cushman claims, individuals in contemporary society are perceiving a diminished capacity to be "masterful and bounded,"59 it is no surprise that more and more individuals are experimenting with "skin eroticism" and turning to their bodies as frontiers for establishing a sense of spiritual and social identity. Although Mary Douglas contends that the more tightly a social structure controls an individual, the more control an individual relinquishes over his or her conduct and body, the contemporary trend of body alteration appears to be a rebellious struggle to regain a grounded sense of self, and achieve the narcissistic paradox of individuation and yet integration into a spiritual and subcultural cradle that will impart a feeling of social and spiritual identity.
- Hewitt, Kim, Mutilating the Body: Identity in Blood and Ink, Bowling Green State University Popular Press: Bowling Green, 1997.

Narcissistic Personality Disorder and Suicidal Behavior in Mood Disorders

- Coleman, D., Lawrence, R., Parekh, A., Galfalvy, H., Blasco-Fontecilla, H., & Brent, D. et al. (2017). Narcissistic Personality Disorder and suicidal behavior in mood disorders. Journal Of Psychiatric Research, 85, 24-28. doi: 10.1016/j.jpsychires.2016.10.020

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about body narcissism. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
What is one definition of pathological narcissism? Record the letter of the correct answer the Answer Booklet.