Psychoanalytic Perspective

The observation that right-hemisphere patients are inappropriately unconcerned is not based on deep psychological investigations. It is based on simple bedside evaluations of mood or psychometric pencil-and-paper tests such as the Minnesota Multipha-sic Personality Inventory (MMPI) or Beck Depression Inventory, which rely on the patient's own assessment of his or her mood. Our group has carried out an investigation that bypasses such explicit approaches. A series of five patients with damage to the perisylvian convexity of the right hemisphere were investigated in psychoanalytic psychotherapy [see Kaplan-Solms and Solms (2000), Chapter 8, for details, or Turnbull et al., 2002 for a quantitative analysis of the emotional life of these patients].

The first two patients exhibited typical features of the right-hemisphere syn-drome—they were incompletely aware of their (substantial) cognitive and physical deficits and they neglected the left-hand side of space (including the left side of their own bodies). They also displayed classical emotional indifference to their disabilities. However, this "indifference" was quickly observed to be a highly fragile state. In their psychotherapy sessions, both patients burst into tears for brief moments during which they seemed to be overwhelmed by emotions of the very kind that are normally conspicuous by their absence. This gave the impression of suppressed sadness, grief, dependency fears, and the like rather than a true absence of such feelings.

For example, one of these patients—Mrs. M—found herself suddenly bursting into uncontrollable tears while reading a book (see Kaplan-Solms and Solms, 2000, pp. 167-172). She then regained her composure and continued reading. When asked the next day by her therapist what she had been reading when she started to cry, she couldn't remember. All that she could recall was that it had something to do with a court case. On further investigation, it turned out that she had been reading about a court case involving parents who were fighting for compensation for a thalidomide child. Mrs. M, who had suffered a severe stroke during childbirth and lost the use of her left arm and leg, had clearly identified her own disability with that of the thalidomide child. However, she was completely unaware of this connection. Mrs. M also (who was of Eastern European, Jewish descent) burst into tears repeatedly while watching the film Fiddler on the Roof. It would clearly be erroneous to claim that this patient could not experience negative emotions; more accurate would be to say that she could not tolerate them, particularly feelings of loss.

The second case was a man (Mr. C; see Kaplan-Solms and Solms, 2000, pp. 160-167). He too was paralyzed by a right-hemisphere stroke but "unaware" of his deficit. Accordingly, his physiotherapist was unable to enlist his cooperation in trying to teach him how to walk again. He seemed oblivious of his deficit and totally unconcerned about it. When recounting the relevant events to his psychotherapist the next day, however, he suddenly burst into tears. When she probed the underlying feelings, Mr. C blurted out: "but look at my arm, what am I going to do if it doesn't recover, how am I ever going to work again." He then regained his composure and reverted to his typical "indifferent" state. This behavior is not consistent with the somatic monitoring hypothesis. Mr. C was not unaware of the state of his body. Rather, he had suppressed conscious awareness of the state of his body. Attention is not an emotionally neutral function. As with Mrs. M, such occurrences were common with this patient. They were also not very difficult to understand. Both of these cases were intolerant of the depressive feelings associated with their loss (which they were certainly unconsciously aware of), and they were therefore unable to work through these feelings by the normal process of mourning.

Failures in the process of mourning take many forms. In the well known "Mourning and Melancholia," Freud (1917) contrasted the normal process of mourning with the pathology of melancholia (i.e., clinical depression). He argued that, in mourning, a person gradually comes to terms with loss by giving up (separating from) the lost love object, whereas in depression this cannot happen because the patient denies the loss. You cannot come to terms with a loss if you do not acknowledge its existence. Freud argued that this was particularly apt to happen if the original attachment to the lost object had been a narcissistic one, in which the separateness of the love object is not recognized but rather treated as if it were part of the self—in contrast to object love, a more mature form of attachment, where the independence of the love object is acknowledged. Freud argued that in melancholia the patient denies the loss of the love object by identifying himself with it, by literally becoming that object in fantasy. The depression itself then results from the internalization of the feelings of resentment toward the object that has been abandoned (so that the narcissist attacks the internalized object with all the ruthless vengefulness of a lover scorned).

This explanation also seems to fit the third case of right-hemisphere syndrome that was investigated psychoanalytically. This case, Mrs. A (see Kaplan-Solms and Solms, 2000, pp. 173-179), suffered severe spatial deficits, neglect, and anosognosia but, at the same time, she was profoundly depressed. This is unusual for right-hemisphere patients, producing a paradoxical situation in which the patient was unaware of a loss (anosognosia) and yet simultaneously displaying severe depressive reactions to it. She was constantly in tears, lamenting the fact that she was such a burden to the medical and nursing staff, whose generous attention she did not deserve since she was not fit to live, and so on. The psychoanalytic investigation revealed that Mrs. A was in fact, unconsciously very much aware of her loss, but she was denying it by means of the introjective process described above. Unconsciously, Mrs. A did have an internalized image of her damaged, crippled self, and she attacked that image to the point of twice attempting to kill herself. In this case, the patient was overwhelmed by feelings of the same type that the previous two patients managed (for the most part) to successfully suppress. In the final two cases, the situation was more complicated still.

A further patient, Mr. D (see Kaplan-Solms and Solms, 2000, pp. 187-197), was anything but unconcerned and indifferent about his deficits. He was absolutely obsessed by them and displayed a symptom mentioned earlier: misoplegia (hatred of the paretic limb). Mr. D had only a mild paresis of the left hand, and he would have been able to use it if he had tried. However, he refused to use the hand and actually demanded that the surgeon cut it off because he loathed it so much. This patient once became so enraged at his hand that he smashed it against a radiator, claiming that he was going to break it to pieces and post the bits of flesh in an envelope to the neurosurgeon who had operated on him. This reaction conveys vividly the emotional state of these patients.

It is interesting that the same lesion site can produce such opposite emotional reactions: unawareness of a limb and denial of its deficits versus obsessive hatred of a limb and its imperfections. This state of affairs almost demands a psychodynamic (or at least some other form of dynamic) explanation. The psychoanalyst who treated these two patients came to the conclusion that their underlying psychodynamics were very similar to those of Mrs. A; they too attacked their internal awareness of their loss, but rather than attempt to kill themselves (like Mrs. A), they reacted by trying to literally detach the hated (damaged) image of themselves—or parts of themselves—from the rest, in order to preserve their intact selves.

No doubt, other permutations are possible.8 What all of these cases have in common is a failure of the process of mourning. Underlying the range of clinical presentations was this common dynamic mechanism: These patients could not tolerate the difficult feelings associated with coming to terms with loss. The superficial differences

8Moss and Turnbull (1996) described a 10-year-old child, with the classic right-hemisphere syndrome, who alternated between a state of denial (anosognosia) and hatred (misoplegia) in relation to his left hand. During the period when he hated it, he said that he wanted to have that arm surgically removed and replaced with the left arm of his mother.

between the patients is attributable to the fact that they defended themselves against this intolerable situation in various ways.

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