Growing up with a Brain-Damaged Mother: Anosognosia by Proxy?

This study compares the developmental outcome of a child in relation to her mother's pathology. The mother suffered from the long-term sequelae of a traumatic brain injury and as a result developed a chronic but mild form of anosognosia (i.e., a lack of awareness of her own sensory and motor deficits). Both mother and daughter underwent psychoanalytic psychotherapy, each in a separate setting. We correlated the psychopathological features of the mother's presentation with the mechanism of denial, described in a dyadic context, comparing the clinical presentation of the mother and that of her 9-year-old daughter. What emerges is a disturbed pattern of development in the child over the seven years since the accident, which closely matches the experience of the mother, who was organically damaged. The feature to appear is an “anosognosic relationship”—a special kind of relationship in which the mother is affected by denial, linked to her brain lesion, and her daughter displays an induced unawareness of her mother's handicaps: an “anosognosia by proxy.” This hypothesis that “by-proxy” phenomenology is ubiquitous is discussed in terms of a particular psychoanalytic model (Sandler & Sandler, 1998a) that considers defense mechanisms present both in adaptive and maladaptive behaviour (i.e., in healthy and in brain-lesioned patients). From this perspective, by-proxy syndromes would be by-products of relations with internal objects that follow the need for an identity of perception by allocating them in external reality through intrapsychic actualizations (Sandler, 1990). Other mechanisms well-known to analysts and involved in these clinical presentations are discussed from a psychoanalytic perspective (Sandler, 1976b). In this respect, anosognosia is viewed as a neurological disorder that exalts the underlying defense mechanism—that is, denial. This study follows the hypothesis that, like every defense mechanisms, denial may either be successful in maintaining a psychic balance, or it may fail and lead to a symptomatological continuum from deep disavowal of one's real condition to obsessional focalization on the disease (as in misoplegia).