Phantom pain is a weird phenomenon. After losing a body part, usually a lower or an upper limb, but not infrequently a missing breast, tooth or an internal organ, the sufferer is plagued, in more cases than not, with sensations of pain arising from where the missing part should be. One can feel one's toes or fingers, or the entire missing limb, often uncomfortably, even excruciatingly, with sensations that are described as burning, tingling, stabbing, boring, squeezing, throbbing etc. Psychologically the physical pain is accompanied by mental distress.
Is the missing part crying painfully for its right to continue to exist alongside the rest of the body that is still alive? Or is the pain due to the missing part's mental and brain representation being attacked by other brain regions with the aim of dissolving its organization and incorporating the ensuing fragments to enrich their organizations and purposes and the resistance to this dissolution is what creates the sensations of tingling, stabbing, burning, throbbing etc. at the level of the brain?
If the above is true then the phantom pain is similar to the pain of mourning. Mourning is a reaction to the loss of something valuable, the memory of which wants to keep occupying one's psyche till one adjusts to the adverse consequences of the loss through compensating for them And we know that the loss does not have to be due to death but even when we lose in the other the meaning they held for us and for which we loved them. And the mourning is not limited to loss of living entities like a family member, a close friend, or a pet, but material possessions, even cherished abstractions, which enriched one's life, like loss of a job, loss of status in wealth or social ranking, fading away of one's once good looks, realization that a long sought ambition of becoming somebody extraordinary like a celebrity or a beauty queen or even accomplishing a coveted career as a doctor or a lawyer which is no longer tenable, expulsion from a prized organization like one's church or trade union or motherland or street gang membership.
Is the above description of mourning backed by clinical experience and what is the role of pain in it?
Let us examine the behavior of a patient of mine who came to me to help him tide over the mental pain he was feeling on finding that his wife was cheating on him and when caught had left him and their two young children for the other man. He was determined to never forgive and never go back with her even if she returned which his children kept asking her to do. She had lost her value to him as a wife. What he most ardently wanted was not to think about her at all and to resume life with others but without her being in the picture. But what was happening in reality was just the reverse. He had isolated himself from all interests and people in his life and was thinking about her 24/7, crying over all the good times they had had in the past, followed by feelings of pain by contemplating as to how she had done him wrong and by imagining her making love to the rival and how he will find alternate superior ways of living to get even with her.
Mourning appears to be a psychological and physiological brain process by means of which a person reorganizes his/her living situation so as to be able to continue to exist without the benefit of whatever the loss object had been doing for him/her hitherto. If we examine the behavior of someone whose beloved spouse dies, we see that he shuts himself from all other interests and his mind is concentrated only upon the memories of his times with the lost one, which he once again experiences in great intensity with all the emotions attached, with the aim of "dampening" them so as to put them to rest and to get free of their incorporation in his future conduct. This dampening of the departed person's memories is accomplished through generation of pain. The mechanism that generates the pain appears to be analogous to what happens in depression. While in depression there is an across the board inhibition mourning attempts to selectively inhibit all those behaviors in which the lost object was a significant contributor. Fundamentally depression appears to be mourning gone overboard; spreading of the mental processes of inhibition beyond their original aim.
The pain's role in mourning and depression appears to be biphasic. The pain first compels attention to prevent the loss from being forgotten and becoming permanent, goading one to do something about it and to undo the loss. But the gradual realization that there is no prospect of succeeding in this endeavor the pain initiates the next phase of putting inhibitions on all those behaviors where the lost object was one's associate in the past with the aim of reorganizing their planning so in the future one would be able to do it without the presence of the lost person.
By generating pain, which at the cortex would be overactivity of the neuronal circuitry of the homuncular region where the missing part is represented along with all its connections to the other parts of the brain, rest of the brain would be compelled to take notice of it leading to its incorporation in their organization causing a reorganization that would try to give a new life to these areas which are now idling. With loss of a hand or a leg the region that most likely will try to usurp its function would naturally be the areas of speech, for what one can no longer do with one's limbs one would attempt to make others do it for oneself through the faculty of language. There is some evidence that the region representing the lips and mouth in the homunculus of an amputee hypertrophies after the loss.
That the phantom pain in an amputated limb is to inhibit the functioning of its psychic representation in the brain as it was when the limb was actually present and to reorganize it so as to become a new auxiliary to the oral region, among other reorganizations, was illustrated in a very educational fashion in the recurring dreams of a patient of mine who just 10 months ago had a below knee amputation on one of her legs.
A divorcee in her late forties, with two grown children, who lives with her cantankerous mother, and who has since childhood suffered from Obsessional Neurosis due to childhood abuse, the effects of which were not just psychic but spilled into the psychosomatic sphere and over the years she developed numerous medical and psychological problems, the former primarily emanating from autoimmune disturbances, which ended up after years of suffering in an emergency amputation of her right limb. They amputation occurred without any prior hint that such a narcissistic assault was about to happen. She had leg pain for over a year, but it was dismissed by numerous doctors a either psychogenic or part of her sciatica, and when the correct diagnosis was made, the gangrene had already set in, with all her leg arteries irreversibly blocked, and there was no choice but to amputate. From the time of the correct diagnosis to the amputation was just three days, with only 24-hours given to make up her mind whether she wanted below the knee or above the knee amputation or certain death from not choosing one or the other, from the creeping gangrene. With considerable narcissism in her good looks, for she is a beautiful woman, it was a complete shock for her. She had naturally chosen below-knee amputation, the decision made in a twilight zone, with the feeling that all that was happening was a dream.
After going through a period when she was numb to the reality of what had happened, a great degree of anger, depression and suicidal impulses emerged. She was furious with the doctors for not diagnosing her problem in time. Their lack of concern for her illnesses, feeling that they did not take her leg pain seriously because she had so many medical problems arising from her autoimmune pathology. She also suspected, and correctly, that her having Medicaid, a low paying insurance, with too many problems, made the doctors listen to her complaints less attentively in comparison to their better paying patients.
About 10 months after the amputation she began having a recurrent dream:
I am in my bed sleeping (this is part of the dream and not description of when she dreams). I get up already to go and not realizing that I do not have both my legs start off only to fall. I look down at the legs. The stump of the amputated leg has a mouth that has big cartoon lips. It is like watching a cartoon but not at all pleasant. Those lips berate me. "This is what happens when you do not take care of your body. You did not pay attention. This is your fault. God did this to you." There is great fright associated with it. It scares the crap out of me as I listen to that talking leg.
At times, which is the alternate version of the dream, I am whole and I run and run, effortlessly, enjoying the freedom of my leg activities, with both of my legs there. The affect is that of joy
The dream required no interpretation for its meaning is transparent. The alternate version is simple wish fulfillment. The painful version is working through to get reconciled to the trauma and the narcissistic injury. The cartoon like lips could be an accurate description of the labial region of the homunculus getting hypertrophied. As to why the lips berate her the patient said it must be a warning on part of the missing leg to not allow the other leg to be lost too out of neglect and to take care of my health diligently which I did not do with the leg that I lost. I should not have accepted the shallow explanations by the doctors that it is sciatica or non-specific pain or in my head.
To me however, the striking similarity of this beratement with the beratement that the superego imposes upon the ego in obsessional neurosis and in melancholia was the most intriguing. In her case the lips of the stump were doing what in depressed patient their sense of guilt does through the agency of superego upon the ego. This beratement in depression to me appears to be an exaggeration of the mourning in normal people. In mourning the memory of the lost person is put to rest by bringing them up in great intensity and then putting an inhibition upon them. In depression the memory of the lost person is brought up in great intensity but instead of putting it to rest, it is introjected into the ego, where it is constantly berated and condemned.
It is interesting that the patient while she occasionally does have sensations of touch in the region of toes in the amputated limb, which she finds very weird, she has absolutely no phantom pain.
Is it possible that the phantom pain that occurs in other amputee in her case is emerging in the dreams of beratement and the frightening painful affect associated with them are the substitute for the phantom pain. The similarity of the dream structure with that of the process of mourning and melancholia tells us that the phantom pain too in its essence is no different than mourning and melancholia.
The patient agreed that her bitter complaint that This is what happens when you do not take care of your body. You did not pay attention. This is your fault. God did this to you is not just beratement of herself but behind her guise that of the doctors who were too stupid to diagnose her problem in time and to do something about it when there was still time. And the process is similar to that in melancholia where the patient who laments about being stupid and ugly, lazy and selfish, is in reality making these complaints about the departed person, with whom he still has to settle scores and towards whom he still nurtures grievances, and who he cannot let rest in peace, and whom he makes part of himself, which he can now berate endlessly.
