Abstract
Splitting of the body image was illustrated as a somesthetic aura symptom in three of the 562 entries to the national Migraine Art competitions, confirming previous descriptions of this rare phenomenon in the migraine literature. In this type of self-experienced paroxysmal body schema disturbance, the own body is perceived as being split, usually in the mid-line, into two halves that may be displaced or separated from each other. Splitting of the body image most frequently applies to the migraine sufferer's head. The said phenomenon, the pathomechanisms of which are obscure, must not be confused with the visual illusion of illusory splitting.
Introduction
Splitting of the body image (1) is a body schema disturbance where the subject has the feeling of his or her body being split, usually in the mid-line, into two halves (2). There may also be a sensation of displacement or separation of the split body parts. A variant of this body schema disorder was described as sensation of anomalous position and remoteness of body parts (3, 4) or illusory displacement of limbs (5), where the patient has the impression that one of his limbs is completely detached from his own body and occupies some position nearby or afar. Splitting of the body image, which is most frequently encountered in patients with parietal lesions (5), has been described as a somesthetic aura symptom of migraine by Lippman (6), Lukianowicz (1) and Critchley (7), occurring either in isolated fashion (7) or associated with other types of body schema disturbances (1, 6).
In this paper, we made an assessment of the paintings and drawings produced by migraine sufferers as entries to the four national Migraine Art competitions (8–10). The Migraine Art collection includes a sample of illustrations of splitting of the body image that were used as material for a description of its phenomenological features.
Methods
The Migraine Action Association (formerly the British Migraine Association) and Boehringer Ingelheim UK Limited, a multinational pharmaceutical company, jointly sponsored the four Migraine Art competitions, which produced approximately 900 pictures by migraine sufferers who illustrated the pain, how they felt and what they saw during a migraine attack, and the social implications resulting from the attacks (8). Whilst some artists requested the return of their entries following the contests, most were prepared to leave them at the disposal of the organizers to contribute to a unique collection (9) that currently consists of 562 pieces.
All 562 Migraine Art pictures were examined by both authors and three (0.5%) were identified as representing splitting of the body image according to the criteria of Lukianowicz's (1) taxonomy of body schema disturbances. Of the three artists, two were female and one male, and all were over 16 years of age. An attempt was made to contact the three patients by letter, in which they were asked to describe the migraine experiences illustrated in their entry, submitted to the Migraine Art competition some 10–17 years before. In the two patients who were traced, a diagnosis of migraine with aura could be established on the basis of their responses to a questionnaire (11) assessing the diagnostic criteria of the International Headache Society (12).
Results
The female sufferer portrayed in Fig. 1 feels her ‘head split in half’. According to the artist, this splitting of the body image is accompanied by visual migraine aura symptoms and followed by headaches. Thus, she experiences ‘a sensation of lights flashing, sparks going off in one's eyes, then being half-blinded, slowly sight becomes worse, giving one an unbalanced feeling and powerless to do anything. A dull headache follows, then complete exhaustion for the rest of the day'. The artist adds: ‘A migraine attack is almost impossible to describe to anyone unless they also suffer from them’.
Splitting of the body image associated with visual aura symptoms.
In Fig. 2, entitled ‘The two faces of migraine’, a weight on the left hand side of the head is denoting the ‘feeling of heaviness and pressure making this side appear to be out of line with the other’. The sensation of splitting and displacement of the two halves of the head is represented by the relative positions of the eye, nostril, mouth and chin regions on either side. As further symptoms, the artist has represented phono- and photophobia, visual aura symptoms and depression. ‘Lines by ear denote sound to be highly amplified, as if the ear has become more acute and can hear slight sounds. Redness of the eye and the lines from it denote the tolerance of light to be getting less. All lights seem extremely bright. Sometimes lines of dots appear. A feeling of depression is shown by darkness and slight stubble on face on the left hand side of the picture. The right hand side of the picture shows this side to be unaffected and normal.’
Splitting of the body image associated with visual aura symptoms, photo- and phonophobia, hemicrania and depression.
A similar mid-line splitting of the face together with considerable downward displacement of its left hand side is illustrated in Fig. 3. Both eyes are closed, supporting the notion that the depicted splitting of the face represents splitting of the body image, which can be experienced as an abnormal bodily sensation with closed eyes, rather than the visual illusion of illusory splitting (13).
Splitting of the body image.
Altogether, the three Migraine Art pictures analysed in this study include pictorial representations of further symptoms that suggest associations of splitting of the body image with headache (one picture), phono- and photophobia (one picture), visual hallucinations (two pictures) and depressive mood (one picture).
The two patients who had responded to the follow-up enquiry stated that they had experienced splitting of the body image repeatedly, with a duration of a few minutes (range 1–5 min), often associated with visual aura symptoms and always accompanied or followed by an attack of migraine headache.
Discussion
The three Migraine Art pictures featuring splitting of the body image depict the abnormal bodily sensation of the migraine sufferer's head being split in the mid-line with vertical displacement of the split halves. A review of the literature produces only four similar case reports of the said body schema disturbance in migraine. In one case, the patient had the feeling that in each attack ‘one hand would seem to be a very long way off’ (7, p. 103). In three further migraine patients, splitting of the body image was reported in association with other abnormal bodily sensations, such as macro- and microsomatognosia (6), out-of-body experiences with hallucinations of physical duplication (1), and sensations of falling (6), respectively. The complaints of these three patients were as follows. One of Lippman's (6) patients described: ‘Today my body is as if someone had drawn a vertical line separating the two halves’ (p. 350). Lukianowicz's (1) patient recorded that often during an attack ‘I feel as if my head would split into two parts, right in the middle’ (p. 34). Finally, another patient of Lippman's (6) experienced that ‘My head fell into a deep hole under the head of the bed—it was a very deep hole’ (p. 350). This patient added: ‘I knew it wasn't true, but I was really worried as to my sanity' (p. 350).
Although the number of observations is obviously too small to allow definite conclusions, it is remarkable to note that splitting of the body image applies to the head in all three Migraine Art pictures and in two of the four case reports from the literature, whereas the hand and the whole body are affected each in one case. Similarly, Podoll and co-workers (14, 15) demonstrated that in the body schema disturbance of macrosomatognosia, in which parts or the whole of the body are perceived as abnormally large (16), the head and upper extremities are the body parts most frequently involved, paralleling the extension of their representation in the sensory maps of the human brain, as graphically depicted in Penfield's map of the sensory homunculus in the cortex (17). Thus, the topological distribution of the phenomenon of splitting of the body image, which also shows a clear predominance of the head region, may reflect the organization principles of the sensory maps in the human brain, supporting the notion (15) that the body schema is topologically organized and related to the neural substratum of sensory maps in the human brain.
As a self-experienced paroxysmal body schema disturbance, the phenomenon of splitting of the body image falls within the classification of the syndrome of Alice in Wonderland. According to Todd (18), the Alice in Wonderland syndrome can be characterized by the core symptoms of body schema disturbances and by a number of facultative symptoms, including depersonalization, derealization, visual illusions and illusory alterations in the sense of passage of time. Chapter 19 of Lewis Carroll's novel Sylvie and Bruno (19), first published in 1889, includes the description of ‘… a nursemaid going “in two halves”’ (p. 200), providing an illustration of the salient features of splitting of the body image (Fig. 4). As Lewis Carroll was a migraine sufferer (20), Lippman (6) and Todd (18) suggested that he had used his own migraine experiences as a source of artistic inspiration, which may not only have been true for his two Alice books (21), but also for the two volumes of Sylvie and Bruno.
Lewis Carroll's Sylvie and Bruno (illustration by Harry Furniss).
