Consciousness and body image: lessons from phantom limbs, Capgras syndrome and pain asymbolia

Words such as 'consciousness' and 'self' actually encompass a number of distinct phenomena that are loosely lumped together. The study of neurological syndromes allows us to explore the neural mechanisms that might underlie different aspects of self, such as body image and emotional responses to sensory stimuli, and perhaps even laughter and humour. Mapping the 'functional logic' of the many different attributes of human nature on to specific neural circuits in the brain offers the best hope of understanding how the activity of neurons gives rise to conscious experience. We consider three neurological syndromes (phantom limbs, Capgras delusion and pain asymbolia) to illustrate this idea.

Possible mechanisms of anosognosia: a defect in self-awareness

Anosognosia of hemiplegia is of interest for both pragmatic and theoretical reasons. We discuss several neuropsychological theories that have been proposed to explain this deficit. Although for psychological reasons people might deny deficits, the denial hypothesis cannot account for the hemispheric asymmetries associated with this disorder and cannot explain why some patients might deny one deficit and recognize another equally disabling deficit. There is some evidence that faulty feedback from sensory deficits, spatial neglect and asomatognosia might be responsible for anosognosia in some patients. However, these feedback hypotheses cannot account for anosognosia in all patients. Although the hemispheric disconnection hypothesis is appealing, disconnection is probably only a rare cause of this disorder. The feedforward intentional theory of anosognosia suggests that the discovery of weakness is dependent on attempted action and some patients might have anosognosia because they do not attempt to move. We present evidence that supports this theory. The presence of one mechanism of anosognosia, however, does not preclude the possibility that other mechanisms might also be working to produce this disorder. Although a large population study needs to be performed, we suspect that anosognosia might be caused by several of the mechanisms that we have discussed. On the basis of the studies of impaired corporeal self-awareness that we have reviewed, we can infer that normal self-awareness is dependent on several parallel processes. One must have sensory feedback and the ability to attend to both one's body and the space where parts of the body may be positioned or acting. One must develop a representation of the body, and this representation must be continuously modified by expectations (feedforward) and knowledge of results (feedback).

The perception of phantom limbs. The D. O. Hebb lecture

Almost everyone who has a limb amputated will experience a phantom limb--the vivid impression that the limb is not only still present, but in some cases, painful. There is now a wealth of empirical evidence demonstrating changes in cortical topography in primates following deafferentation or amputation, and this review will attempt to relate these in a systematic way to the clinical phenomenology of phantom limbs. With the advent of non-invasive imaging techniques such as MEG (magnetoencephalogram) and functional MRI, topographical reorganization can also be demonstrated in humans, so that it is now possible to track perceptual changes and changes in cortical topography in individual patients. We suggest, therefore, that these patients provide a valuable opportunity not only for exploring neural plasticity in the adult human brain but also for understanding the relationship between the activity of sensory neurons and conscious experience. We conclude with a theory of phantom limbs, some striking demonstrations of phantoms induced in normal subjects, and some remarks about the relevance of these phenomena to the question of how the brain constructs a 'body image.'

Reorganization of auditory cortex in tinnitus

Magnetic source imaging was used to determine whether tonotopy in auditory cortex of individuals with tinnitus diverges from normative functional organization. Ten tinnitus subjects and 15 healthy controls were exposed to four sets of tones while magnetoencephalographic recordings were obtained from the two cortical hemispheres in sequence. A marked shift of the cortical representation of the tinnitus frequency into an area adjacent to the expected tonotopic location was observed. The Euclidean distance of the tinnitus frequency from the trajectory of the tonotopic map was 5.3 mm (SD = 3.1) compared with a distance of 2.5 mm (SD = 1.3) of a corresponding frequency in the healthy controls (t = 3.13, P < 0.01). In addition, a strong positive correlation was found between the subjective strength of the tinnitus and the amount of cortical reorganization (r = 0.82, P < 0.01). These results demonstrate that tinnitus is related to plastic alterations in auditory cortex. Similarities between these data and the previous demonstrations that phantom limb pain is highly correlated with cortical reorganization suggest that tinnitus may be an auditory phantom phenomenon.

Psychological management, prevention and treatment of phantom pain after amputations for tumours

Amputation for tumours is rarely carried out nowadays and has few specific technical features, apart from the rare cases where ingenuity is required to gain a few centimetres in length of a stump. As far as possible, the decision for amputation should not be imposed; it is better that the patient himself should take the initiative. The prosthesis and its constraints should be described honestly to avoid subsequent disappointment. Prevention of a painful phantom limb must always be undertaken, and based on certain operative and perioperative precautions. The most important factors are treatment by psychotropic agents and the quality of the human relationships between patient and surgeon.

Evidence for a change in neural processing in phantom limb pain patients

The present study was designed to investigate differences in neural processing of pain-related semantic information in amputees with and without chronic phantom limb pain and healthy controls. One-hundred-and-twenty words (40 neutral, 40 body-related, 40 pain-related) were presented in pseudorandom order to probe group differences in the perception of pain-related information. Visual evoked potentials (VEP) to the words were recorded from 11 scalp locations, EMG was measured at the stump and the contralateral side and bilaterally from the M. corrugator. In addition, heart rate and skin conductance responses were obtained. Both early and late VEP components were altered. Pain-free amputees showed a reduced N100 amplitude compared to phantom limb pain patients and healthy controls whereas the phantom limb pain patients displayed a significantly enhanced late positivity (500-800 msec after word onset). VEP components were unaffected by word type. The peripheral EMG responses were significantly different among the groups: phantom limb pain patients showed larger EMG reactions on the stump than on the contralateral side, whereas pain-free amputees showed the opposite effect. The data suggest an enhanced central and peripheral processing of visual stimuli in phantom limb pain patients.

Pain memories in phantom limbs: a case study

Pain experienced in a limb prior to amputation may influence the course of phantom limb pain many months later. Katz and Melzack (1990) found that 42% of their sample reported a 'somatosensory pain memory' which resembled the quality and location of a painful, or non-painful pre-amputation sensation. For many amputees, pain memories are vivid experiences which incorporate both emotional and sensory aspects of the pre-amputation pain (Katz 1992). Katz and Melzack (1990) suggest that sensory input will 'trigger' somatosensory pain memories while the affective component of a pain memory is generated by the intensity, quality and location of the current experience of phantom limb pain. The present case study used a diary design to examine whether 'triggers' could be identified for somatosensory pain memories. Over a 9-month period, the patient reported daily experience of ongoing phantom limb pain, generally confined to the distal part of the limb, and 5 episodes of injury-related phantom limb pain, primarily experienced in the calf of the missing limb. A 'trigger' was identified for each of the episodes of injury-related phantom limb pain, and a significant finding in this study was that two episodes of injury-related phantom limb pain were associated with cognitive and/or emotional, rather than sensory 'triggers'.

Psychosomatic treatment of phantom limb pain with post-traumatic stress disorder: a case report

The successful treatment of severe left lower limb phantom pain is reported. Hypnosis and antidepressant drugs were the basis for the treatment which controlled the phantom limb pain and an associated post-traumatic stress disorder.

Synaesthesia in phantom limbs induced with mirrors

Although there is a vast clinical literature on phantom limbs, there have been no experimental studies on the effects of visual input on phantom sensations. We introduce an inexpensive new device--a 'virtual reality box'--to resurrect the phantom visually to study inter-sensory effects. A mirror is placed vertically on the table so that the mirror reflection of the patient's intact had is 'superimposed' on the felt position of the phantom. We used this procedure on ten patients and found the following results. 1. In six patients, when the normal hand was moved, so that the phantom was perceived to move in the mirror, it was also felt to move; i.e. kinesthetic sensations emerged in the phantom. In D.S. this effect occurred even though he had never experienced any movements in the phantom for ten years before we tested him. He found the return of sensations very enjoyable. 2. Repeated practice led to a permanent 'disappearance' of the phantom arm in patient D.S. and the hand became telescoped into the stump near the shoulder. 3. Using an optical trick, impossible postures--e.g. extreme hyperextension of the fingers--could be induced visually in the phantom. In one case this was felt as a transient 'painful tug' in the phantom. 4. Five patients experienced involuntary painful 'clenching spasms' in the phantom hand and in four of them the spasms were relieved when the mirror was used to facilitate 'opening' of the phantom hand; opening was not possible without the mirror. 5. In three patients, touching the normal hand evoked precisely localized touch sensations in the phantom. Interestingly, the referral was especially pronounced when the patients actually 'saw' their phantom being touched in the mirror. Indeed, in a fourth patient (R.L.) the referral occurred only if he saw his phantom being touched: a curious form of synaesthesia. These experiments lend themselves readily to imaging studies using PET and fMRI. Taken collectively, they suggest that there is a considerable amount of latent plasticity even in the adult human brain. For example, precisely organized new pathways, bridging the two cerebral hemispheres, can emerge in less than three weeks. Furthermore, there must be a great deal of back and forth interaction between vision and touch, so that the strictly modular, hierarchical model of the brain that is currently in vogue needs to be replaced with a more dynamic, interactive model, in which 're-entrant' signalling plays the main role.

The role of coping in adjustment to phantom limb pain

Research has indicated that the way individuals cope with pain may influence pain, and physical and psychological adjustment. The present study assessed the relationship between coping strategy use and adjustment in amputees with phantom limb pain (PLP). Coping strategies were measured using the Coping Strategies Questionnaire (CSQ) and their relationship with adjustment was examined using both composite scores and individual strategy scores. The results indicated that the relationship between coping and adjustment was primarily explained by the use of strategies within the 'Helplessness' factor of the CSQ. A clearer picture of coping strategy use was gained from examining individual strategies rather than the composite measures. Catastrophizing explained the largest proportion of variance in pain report (26%), while increasing behavioral activity and hoping or praying strategies explained a smaller proportion of the variance (3% and 1%, respectively). Catastrophizing also explained a large proportion of the variance in physical and psychosocial dysfunction (11% and 22%), while hoping or praying strategies accounted for only a small proportion of the variance in physical dysfunction (3%), and re-interpreting pain sensations accounted for a small proportion of the variance in psychosocial dysfunction (3%). The findings in this study have important clinical implications in that coping strategy use was associated with increased, rather than decreased, levels of pain and disability. However, since the reported use of coping strategies in the present study was low, further research, perhaps utilizing other measures of coping, is required to clarify these findings.

Phantom limb experiences in congenital limb-deficient adults

This case report describes phantom limbs in four adults with congenital limb deficiency. Case 1, with congenital absence of the left arm below the elbow, received a minor injury of the stump at age 16 and subsequently developed a full-length phantom arm, hand and fingers. Cases 2 and 3, at the ages of 26 and 30, underwent minor surgery of the lower limbs and subsequently developed vivid, full-length phantoms of their legs. Case 4, aged 31, was born with a shortened and deformed right leg, and underwent amputation of the foot and deformed part of the leg at age 3. Beginning at age 6, she developed a full-length phantom leg and foot that touched the floor, which persisted for more than 20 years. The descriptions by these four adults lend credibility to earlier reports of phantom limbs in congenital limb-deficient children. They also indicate that these phantoms may persist into adulthood.

Pain: past, present and future

Descartes' concept that pain is produced by a direct, straight-through transmission system from injured tissues in the body to a pain centre in the brain has dominated pain research and therapy until recently. The gate control theory of pain, published in 1965, proposes that a mechanism in the dorsal horns of the spinal cord acts like a gate which inhibits or facilitates transmission from the body to the brain on the basis of the diameters of the active peripheral fibers as well as the dynamic action of brain processes. As a result, psychological variables such as past experience, attention and other cognitive activities have been integrated into current research and therapy on pain processes. The gate control theory, however, is not able to explain several chronic pain problems, such as phantom limb pain, which require a greater understanding of brain mechanisms. A new theory of brain function, together with recent research that has derived from it, are described. They throw light on complex pain problems and have important implications for basic assumptions in psychology.

The use of pain coping strategies by patients with phantom limb pain

Previous research has demonstrated a relationship between the use of pain coping strategies and the level of pain and psychological distress experienced by patients suffering from a variety of chronic pain syndromes. The present study assessed coping strategy use in patients suffering from phantom limb pain by means of the Coping Strategies Questionnaire (CSQ). Sixty phantom limb pain patients completed the CSQ and measures of pain and psychological distress. The factor structure of the CSQ was found to be broadly similar to that obtained in other studies of chronic pain. Three factors reflecting 'Cognitive Coping', 'Helplessness' and 'Pain Denial' were found. Both pain report and psychological distress were found to be related to use of strategies within factor 2 (Helplessness), the number of different drugs patients used, and the time they had experienced phantom limb pain. Twenty percent of the variance in pain scores and 19% of the variance in psychological distress were significantly explained by coping strategies included in the 3 factors on the CSQ. Patient history variables significantly explained a further 14% of the variance in pain scores and 14% of the variance in psychological distress. Examination of regression analyses of the subscales of the CSQ revealed that catastrophising explained the largest proportion of the variance in pain report and psychological distress.

Fluoxetine in phantom limb pain

Complete recovery of phantom limb pain of five years' duration occurred in a 71-year-old man following treatment with fluoxetine. There was no coexisting affective disorder. Further research is indicated in view of the postulated role of lowered central 5-hydroxytryptamine activity in the genesis and maintenance of chronic pain.

Delusional reduplication following closed-head injury

Somatic delusions following brain injury are not uncommon, and have been well documented in the literature. This study documents a case of somatic delusion which was seen in a patient following a head injury secondary to a motorcycle accident. Although perhaps not typical it serves to illustrate an interesting example of a somatic delusion following head trauma. On recovery from coma this patient reported the existence of a 'third arm' adjacent to the limb that had received the greatest impact in the accident. The patient was unreceptive to any counter-persuasions and in fact remained largely unconcerned about this addition to his anatomy. A thorough neuropsychological evaluation was carried out in an attempt to seek an explanation for this phenomenon. The results suggest that the phenomenon has at least a partly psychiatric aetiology rather than a purely neurological foundation.

Multiple phantom limbs in a child

This case report describes multiple phantom feet in a child after amputation of a leg. The subject is a 16-year-old girl who was born with a right leg 10 cm shorter than the left and who at the age of 6 was amputated below the right knee so that she could wear a prosthesis that would give her normal mobility. The girl reports that she subsequently experienced 2 phantom feet and 3 sets of phantom toes which have persisted to the present time. Each phantom has a distinct size, length and position in relation to the others and each is also the site of vivid sensations such as heat, tickle, and fatigue as well as voluntary and involuntary movement. She also describes sensations that resemble sensations experienced before the amputation: one of her phantom feet feels flat and locked into a forward position which corresponds with the actual shape and position of her congenitally deformed amputated foot. The implications of multiple phantoms are discussed with reference to recent concepts of phantom limbs.

Psychophysical correlates of phantom limb experience

Phantom limb phenomena were correlated with psychophysiological measures of peripheral sympathetic nervous system activity measured at the amputation stump and contralateral limb. Amputees were assigned to one of three groups depending on whether they reported phantom limb pain, non-painful phantom limb sensations, or no phantom limb at all. Skin conductance and skin temperature were recorded continuously during two 30 minute sessions while subjects continuously monitored and rated the intensity of any phantom limb sensation or pain they experienced. The results from both sessions showed that mean skin temperature was significantly lower at the stump than the contralateral limb in the groups with phantom limb pain and non-painful phantom limb sensations, but not among subjects with no phantom limb at all. In addition, stump skin conductance responses correlated significantly with the intensity of non-painful phantom limb paresthesiae but not other qualities of sensation or pain. Between-limb measures of pressure sensitivity were not significantly different in any group. The results suggest that the presence of a phantom limb, whether painful or painless, is related to the sympathetic-efferent outflow of cutaneous vasoconstrictor fibres in the stump and stump neuromas. The hypothesis of a sympathetic-efferent somatic-afferent mechanism involving both sudomotor and vasoconstrictor fibres is proposed to explain the relationship between stump skin conductance responses and non-painful phantom limb paresthesiae. It is suggested that increases in the intensity of phantom limb paresthesiae follow bursts of sympathetic activity due to neurotransmitter release onto apposing sprouts of large diameter primary afferents located in stump neuromas, and decreases correspond to periods of relative sympathetic inactivity. The results of the study agree with recent suggestions that phantom limb pain is not a unitary syndrome, but a symptom class with each class subserved by different aetiological mechanisms.

Psychophysiological contributions to phantom limbs

Recent studies of amputees reveal a remarkable diversity in the qualities of experiences that define the phantom limb, whether painless or painful. This paper selectively reviews evidence of peripheral, central and psychological processes that trigger or modulate a variety of phantom limb experiences. The data show that pain experienced prior to amputation may persist in the form of a somatosensory memory in the phantom limb. It is suggested that the length and size of the phantom limb may be a perceptual marker of the extent to which sensory input from the amputation stump have re-occupied deprived cortical regions originally subserving the amputated limb. A peripheral mechanism involving a sympathetic-efferent somatic-afferent cycle is presented to explain fluctuations in the intensity of paresthesias referred to the phantom limb. While phantom pain and other sensations are frequently triggered by thoughts and feelings, there is no evidence that the painful or painless phantom limb is a symptom of a psychological disorder. It is concluded that the experience of a phantom limb is determined by a complex interaction of inputs from the periphery and widespread regions of the brain subserving sensory, cognitive, and emotional processes.

Pathophysiology and management of phantom limb pain

Phantom pain phenomenon is a poorly understood but relatively common sequela of limb amputation that may result in significant psychological and physical morbidity. In this review, proposed pathoneurophysiological mechanisms for the development of phantom pain are reviewed as well as psychological mechanisms that may be involved. The authors recommend an integrated approach to management of chronic phantom pain that takes into consideration the multiple factors that may contribute to its etiology.

What do chronic pain patients think of their pain? Towards a pain cognition questionnaire

The three-systems model of chronic pain emphasizes the partially independent relationship among physiological, gross motor and verbal-cognitive responses of chronic pain patients. This study describes the development of an assessment instrument representing a measure for the verbal-cognitive response system of chronic pain. Fifty items, each of which is assigned to one of five factors (pain impact, catastrophizing, outcome efficacy, acquiescence and reliance on health care) constitute the new Pain Cognition List (PCL). The PCL was developed using a Dutch back pain population and proves to be stable across sex and back pain diagnosis. By means of three experiments the PCL is shown to be reliable and sufficiently valid. The PCL might be a promising tool for identifying pain patients whose pain problem is mainly controlled by cognitive factors.

Phantom representations of congenitally absent limbs

It has been widely claimed that phantom limbs are not experienced by children born without the part or who have it amputated in early childhood. This review looks at some reported cases of such phantoms, as well as a lesser known account that shows that phantoms of aplasics can be vivid and dexterous. Reasons for the infrequency of such reports are examined, and some implications for understanding the development of the body schema are proposed.

The relationship between situational stress and phantom limb pain: cross-lagged correlational data from six month pain logs

This study reports the results of the first investigation into the relationship between situational stress and phantom limb pain. Twenty-seven male amputees recorded their pain and overall stress levels daily for 180 days using a 1-10 rating scale. Three possible relationships into the etiology and/or maintenance of phantom limb pain were examined using cross-lagged correlational techniques: an isomorphic relationship (same time increases in pain lead to same time increases in stress and vice versa), a consequence relationship (increases in pain precede increases in stress), and a precursor relationship (increases in stress precede increases in pain). Thirty-seven per cent of subjects demonstrated some significant precursor relationship. Although support was found for all three hypotheses, the most frequently observed relationship was the isomorphic one. Seventy-four per cent of subjects demonstrated some significant stress-pain relationship. The results lend support to the psychological theory underlying the use of psychophysiological interventions such as biofeedback and relaxation therapy in amputees with phantom limb pain.

The mystery of phantom pain: growing evidence for psychophysiological mechanisms

The direct, and much of the indirect, evidence supporting the existence psychophysiological mechanisms for phantom limb pain is reviewed. Phantom pain is shown to be a symptom class composed of different, but similarly described problems, each having its own underlying mechanisms. At least some descriptive types of phantom pain probably have mainly peripheral, as opposed to only central, origins. Although much of the direct data are preliminary, burning phantom pain is probably related to decreased blood flow in the residual limb, while cramping phantom pain is mainly related to spikelike muscle spasms in the major muscles of the residual limb. Little support is provided for psychological causes for phantom pain, but the expression of phantom pain does appear to be influenced by psychological mechanisms similarly to the ways other chronic pain conditions are influenced. The importance of a careful psychophysiological assessment of patients to treatment success is discussed. Because several different mechanisms are involved, no one treatment is likely to be effective for all of the different types of phantom pain. Appropriate combinations of self-regulation strategies aimed at controlling the underlying physiological problems are likely to be effective in reducing the incidence and severity of burning and cramping types of phantom pain.

[Phantom pain]

More than 50% of all amputees are reporting phantom pain. There are several different neuropathophysiological and psychopathological models of phantom pain. However, these models can only partially explain the genesis and the occurrence of phantom pain. The suggested treatments vary largely from author to author. This is due partly to the limited response to all known and applied therapeutic procedures. These complications imply that the therapeutist will be faced with the special challenge of long-term care and support of amputees suffering from phantom pain.

Stump and phantom limb pain

Recent literature suggests that phantom pain and stump pain have closely related physiologic mechanisms and that treatments frequently overlap. Decreased blood flow in the residual limb is related to burning and tingling phantom and stump pain, whereas spasms in major muscles of the residual limb precede cramping phantom and stump pain. There is little support for psychological mechanisms underlying the vast majority of chronic phantom and stump pain problems, but these mechanisms can exacerbate both acute and chronic pain. It is critically important to educate patients about the process of amputation and the physiologic mechanisms of phantom sensation and pain in order to minimize magnification of pain due to stress. Acute stump pain usually responds well to traditional interventions based on identifying and correcting specific problems in the residual limb. Most traditional treatments for phantom pain and chronic stump pain are not effective for more than a few months. Recommended treatments are related to underlying mechanisms. For chronic phantom and stump pain, burning sensations are treated with interventions designed to increase blood flow to the residual limb, whereas cramping sensations are treated with interventions that reduce muscle spasms.

Experiences of phantom limb sensations in dreams

Phantom limb sensations in the waking state and in dreams were examined in 84 limb-amputated patients. These phenomena were divided into complete, reduced, intermittent and nonexisting phantom limb. Common features as well as differences between the phantom limb in the waking state and in dreams were characterized and illustrated by casuistics and dream reports. Thus it was shown that nearly half the patients had the same, whereas the others had a different phantom limb in the waking state and in dreams.

Early Psychological Aspects of Severe Hand Injury

We investigated the incidence and nature of psychological symptoms occurring during the first two months after severe hand injuries. 94% of patients had significant symptoms at some point early in rehabilitation, including nightmares (92%), flashbacks (88%), affective lability (84%), preoccupation with phantom limb sensations (13%), concentration/attention problems (12%), cosmetic concerns (10%), fear of death (5%), and denial of amputation (3%).

Two months later, flashbacks (63%) remained pronounced. Nightmares (13%), affective lability (48%), concentration/attention problems (5%), fear of death (0%), and denial of amputation (0%) declined markedly, while cosmetic concerns (17%) and preoccupation with phantom limb sensations (17%) increased. Based on these findings, we believe that psychological treatment should often be given as part of the rehabilitation process.

Psychological factors influencing chronic phantom limb pain: an analysis of the literature

The behavioral literature concerning chronic phantom limb pain was reanalyzed in order to determine the role of psychological factors in initiating and controlling the intensity of its episodes. Some of the behavioral literature presents an inaccurate picture of amputees who have phantom pain. This apparently happened because many of the data were gathered from those amputees requesting treatment for phantom pain who were referred to mental health professionals. We conclude that phantom pain is similar to other chronic pain syndromes in that episodes are greatly influenced by psychological factors such as stress and depression. Repeated requests for treatment are influenced by personality structure. There is no convincing evidence that major personality disorders are important in the etiology of chronic phantom pain nor that they are more prevalent among those amputees reporting phantom pain than among those not reporting it.

Validity of the General Health Questionnaire (GHQ) in detecting psychiatric disturbance in amputees with phantom pain

The 28-item General Health Questionnaire (GHQ) was validated against the PSE-derived Index of Definition in a sample of amputees with long-standing phantom and stump pain attending a Limb Fitting Centre. This form of the GHQ is a sensitive identifier of overt psychiatric disorder in this setting.

Multiple pain complaints in amputees

A group of amputees complaining of longstanding phantom pain was compared with another comparable group of non-complainers. It was found that those with phantom pain made significantly more complaints of other painful conditions, both related and unrelated to the amputation; they were also more depressed. It is suggested that this association is due to a lowered pain tolerance in the group with phantom pain complaints, and that depression is one factor contributing to this lowered tolerance.

Prevalence and characteristics of chronic phantom limb pain among American veterans. Results of a trial survey

Twelve hundred American amputees who are military veterans were surveyed by questionnaire about their amputations, pain sensitivity, demography, treatment history, stump problems, phantom sensations, and phantom pain. Over sixty percent responded and of these 85 percent reported significant amounts of phantom pain. This is in sharp contrast to both the literature and our clinical experience which indicate that although most amputees seen in a clinical setting report some occasional minor discomfort due to their phantoms, only between one half percent and five percent experience severe phantom pain. There was no relationship between reasons for amputation, use of prosthesis, pain sensitivity, age, years since amputation, or other demographic variables and presence of severity of phantom pain. Those respondents describing phantom pain usually had either momentary episodes of intense, debilitating pain, or virtually continuous discomfort varying in intensity but reaching debilitating levels occasionally. The fairly continuous pains were all similar in description to magnified versions of comfortable phantom sensations reported by other respondents. Few of the reported treatments were of any value.

Phantom pain following limb amputation in a paraplegic. A case report

The pain of the phantom limb remains a diagnostic and therapeutic challenge. A case is reported in which a paraplegic patient with full sensory ablation below T11 experienced phantom limb pain only after actual amputation of one of his legs. This suggests that the cause in this case could only be central in origin. Visual appreciation seems to be an important step in this process.

Body image: a selective review of existing measurement techniques

A selective review of studies concerning body image is presented to illustrate the diversity of approaches which have been adopted. Equivocal definitions of the concept of body image and the difficulties inherent in its measurement are examined and the most popular measurement techniques are described and criticized.