There is an important category of borderline personality disorder (BPD) phe- nomena that is very often overlooked but that may relate to the core of the disorder. It is overlooked, first, because the patient does not report it and, second, because, if reported, it seems incidental to the main clinical picture and also inexplicable. It appears as an almost literal imprint in the body, particularly the skin, of a fragment of traumatic experience. The symptoms of this phenomenon can be understood in terms of a disconnection theory of BPD. They seem to reflect autonomic nervous activity that is independent of, and unco- ordinated with, higher systems, particularly the prefrontal cortex. Rule et al. (2002) have proposed that the orbitofrontal cortex is central to the top-down regulation of subcortical functioning of structures such as the autonomic system, the hypothalamus, and the amyg- dala, all involved in the induction, activation, encoding, and elicitation of emotion. The phe- nomenon considered in this chapter appears to reflect a loss of this regulation and to mani- fest a “dissociation” of the autonomic nervous system activity from prefrontal regulation, particularly as it controls the dermal vascular bed. Quite intricate patterns of skin sensation and even skin markings arise in some traumatized patients with BPD, like sensory “maps” of parts of the trauma.
Here are some examples:
A young woman who had been in therapy for about a year telephoned her therapist some time after a session, which was an unusual thing for her to do, and reported that as she was preparing for a shower, she noticed a number of bruises behind her knees, which bewildered her. The therapist saw her the next day and found several linear but incomplete lesions behind the patient’s knees. This incident might perhaps have been anticipated since, several years before entering therapy, the patient had been investigated by a physician for large linear bruises that occurred intermittently on her arms and legs. The physician was baf- fled by these bruises and could find no cause for them. They became a focus of therapy. One day the patient recalled being made to face the wall and, while she was caned, to keep her legs perfectly straight. “Phew!” she said. “She used to be cruel. Nowadays you would call it child abuse.” It was following this session that the bruises appeared spontaneously behind the patient’s knees.
A middle-aged woman had an intermittent sensation of a male hand under her chin, grasping it between thumb on one side of her chin and fingers on the other. It turned out that this symptom had its origin in her being forced to commit fellatio regularly with her father as a preadolescent.
A woman in her 30s had the strange sensation, from time to time, of something like a silken cord mov- ing obliquely across her face in a wavering line. This sensation occurred particularly when she was anxious. Eventually a link was discovered that related her facial sensation to a car accident some years before. In the moment before impact, she could see that the accident was about to happen and at that instant felt the ter- ror of knowing she was about to die. She was not, however, seriously injured, but, as she lay on the roadside, blood from a scalp wound trickled obliquely across her face.
A woman in her 40s who had been sexually attacked by two men would feel, intermittently, the skin of her forearms twisting laterally. This was a “body memory” of being held down by the arms by one man while the other raped her.
The skin on the face and hands of a woman in her early 30s would, from time to time during a therapeutic session, become blue and mottled, as if from cold. When her therapist inquired about the skin changes, the patient had no explanation for them. It later emerged, however, that during childhood she was punished by being locked in a closet that was totally dark and in a part of the house that was freezing cold. This experi- ence was frightening.
In each of these examples, the symptom represents an element of traumatic memory that was initially unconscious. Janet called hysteria an “ensemble of maladies of representation” (1901, p. 488). Breuer and Freud concurred, noting that “the hysteric suffers mostly from reminiscences” (1895, p. 4). Until recent years, there have been few reports of phenomena such as these. Presumably they were ignored as medically meaningless or discounted as mere fabrica- tions. In the years before World War I, how- ever, they formed part of the descriptive background of the complex condition then called hysteria. The possibility that at least some of these phenomena reflect changes in the blood supply to the skin is suggested by the observations of Janet. He found, for example, that anesthesia of the arm is as- sociated with markedly reduced blood flow (Janet, 1901, p.11). He also described the re- markable case of a young woman, observed over a period of 10 years, who had a persis- tent pulse of 100 and a temperature about 2 degrees Fahrenheit above the normal, sug- gesting a disturbance of autonomic regula- tion of body temperature (Janet, 1925, pp. 1050–1051). Her symptoms could not be explained in terms of illnesses such as thy- rotoxicosis. Her abnormal temperature did not inconvenience her. She complained, however, of fever when she had a slight attack of influenza. Janet noted that the “disorders of the peripheral circulation tak- ing the form of passive dilation of the blood vessels or of vasomotor spasm” (1925, p. 1051) were not uncommon. “A great many of these patients are continually becoming affected with redness or pallor of the skin of various regions” (p. 1051). In several of his patients, “patches on the skin, at first red and hot, and then pale and very cold,