I have been told many times by my patients, often those diagnosed with borderline personality disorder, that their physical pain resulting from various kinds of self-mutilation is preferable to mental/psychic pain.  As a psychobiological-psychoanalyst, I have become convinced that the Cartesian split evident in our psychiatric approach to DSM disorders as being really all ‘brain diseases’, or alternatively, the Axis I disorders are the ‘brain diseases’ and the Axis II disorders are more like ‘mind/social disorders,’ is scientifically untrue and opposed to accumulating research evidence that the human organism is not ‘computed’ from genes or environment alone.  Harvard geneticist Richard Lewontin emphasized that life emerges only from the interaction between genes and environment, there are no genetic factors that can be studied apart from the environment (including the in utero environment).  My patients’ claim that physical pain is preferred to mental pain is backed up by recent neuroimaging research along with psychoanalytic theory of a hierarchy of ‘danger’ situations.

Eisenberger, Lieberman and Williams (2003) examined the neural correlates of a sense of social exclusion and tested the hypothesis that the neural bases of social pain are similar to those of physical pain (see “Does rejection hurt?  An fMRI study of social exclusion” published in the journal Science, Vol. 302. issue 5643, p.290).  Paralleling results from physical pain studies, the results of their study included greater activation of the anterior cingulate cortex (ACC) during social exclusion which correlated positively with self-reported distress.  The ACC is thought to act as a kind of neural ‘alarm system,’ in this case to promote the goal of social connectedness.  Right ventral prefrontal cortex (RVPFC) was also active during exclusion and correlated negatively with self-reported distress.  ACC changes mediated the RVPFC-distress correlation, suggesting that the RVPFC regulates the distress of social exclusion by disrupting ACC activity.

Eisenberger et al (2003) concluded:
“This study suggests that social pain is analogous in its neurocognitive function to physical pain, alerting us when we have sustained injury to our social connections, allowing restorative measures to be taken.  Understanding the underlying commonalities between physical and social pain unearths new perspectives on issues such as why physical and social pain are affected similarly by both social support and neurochemical interventions, and why it hurts to lose someone we love.”

Perhaps the “mental” pain some patients are trying to escape from has to do with a sense of social exclusion, social disconnectedness, a feeling of social isolation which is a form of “psychic” death, and, at times, literal death, as depicted in the clinical research of R. Spitz, Otto Will (see Sacksteder J., Schwartz, D.P., & Akabane, Y. (Eds.). (1987). Attachment and the Therapeutic Process: Essays in Honor of Otto Allen Will, Jr., M.D.  Madison: International Universities Press).  It is reflected in the mortality rates of persons with chronic and severe mental illness living isolated lives in the community (either through actual suicide, severe immuno-suppression, extreme hopelessness, despair, etc.).

Brian Koehler PhD
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net