The history of a concept of a body schema is linked with the fact that the discovery that there is such a thing as a permanent, albeit vague perception that one has of one's own body, has been mainly in observations of its pathological manifestation in the clinic.

Before discussing the relationship of the temporal lobes to the body image, it is necessary to consider briefly some other aspects of the neurology of body image and its disturbances. Further, some clarification of the term body image is required.

This paper describes the phenomenology of depersonalisation and focuses upon the relationship between depersonalisation, self-perception and body image. In discussing this relationship, the influence of certain phenomenological philosophers will be considered. Theoretical discussion of depersonalisation will be limited to those theories that are relevant to the purpose of this paper. Comprehensive reviews of the wide range of theories held to explain depersonalisation have been provided by Sedman (1970) and Oberst (1983).

The term ‘body image’ is used to refer to the picture we have in our minds of the size, shape and form of our bodies; and to our feelings concerning the size, shape and form of our bodies, and its constituent parts.

Clinicians who deal with patients with anorexia nervosa are well acquainted with their patients' inability to recognise their emaciation. The patients' insistence that they are normal weight or even overweight, against clear evidence to the contrary, led Bruch (1962) to state that the misperception reaches “delusional proportions”. Studies of body size perception in anorexia nervosa that have used the ‘body part’ method have invariably found that the patients overestimate their body size (Slade & Russell, 1973; Crisp & Kalucy, 1974; Pierloot & Houben, 1978; Garner et al, 1976; Button et al, 1977; Fries, 1977; Casper et al, 1979) but the majority have not found any significant difference in size estimation between patients and controls (Slade, 1985).

For many decades thinness has been a desirable attribute for women in prosperous northern European and American cultures. Over the last 20 years or so the acceptable female shape has become even slimmer (Garner & Garfinkel, 1980). The increased emphasis on thinness among women is also apparent from the rising number of articles on slimming in women's magazines in recent years.

Bulimia nervosa is a disorder which has only recently been identified and described (Russell, 1979). It is a condition, found almost exclusively in young women, in which episodes of excessive uncontrolled eating are the central feature. Patients with bulimia nervosa usually present at normal weight because they compensate for the bulimic episodes in a variety of ways, such as by inducing vomiting, abusing purgatives and exercising extreme dietary restraint. In addition to these disturbed eating habits, patients with bulimia nervosa have attitudes to their shape and weight similar to those found in anorexia nervosa. They also present with a wide range of neurotic symptoms, particularly of a depressive nature (Russell, 1979; Fairburn & Cooper, 1984). It is generally accepted that these neurotic symptoms are usually a secondary reaction to the core eating disorder rather than of primary diagnostic significance (Fairburn et al, 1985; Cooper & Fairburn, 1986).

DSM-IIIR (American Psychiatric Association, 1987) has revised the Kraepelinian concept of paranoia, but has given it the name of delusional (paranoid) disorder. The description is of an encapsulated, monodelusional disorder with several subtypes as follows: Erotomanic, Grandiose, Jealous, Persecutory, Somatic, Unspecified.

The term ‘dysmorphophobia’ was first defined by Morselli (1886) who wrote of it as “a subjective feeling of ugliness or physical defect which the patient feels is noticeable to others, although his appearance is within normal limits”. A century later there is continuing debate as to its status as symptom, syndrome or discrete psychiatric illness. Misleadingly, it is not a phobia and there is no fear of physical abnormality per se – the ugliness of others is tolerated, although the patient may well be apprehensive regarding the response he anticipates his appearance will provoke in others. As a symptom the feeling may be expressed as a preoccupation with appearance, an obsession, overvalued idea or frank delusion. The accompanying self-consciousness may similarly range to full-blown delusions of reference. To some extent the failure of some authors, reporting on dysmorphophobic patients, to specify clearly the level at which the belief is held, has confounded clarification of the phenomenon.

The skin is by far the largest organ of the body and it performs a variety of important functions. In both a concrete and symbolic sense the skin serves as a boundary separating the inner person from the outer world, self from non-self. It is evident therefore that cutaneous awareness is a central part of overall body image. It should be no surprise to learn how frequently real, imaginary or factitious dermal-pathology may occur in association with psychiatric disorder. The false idea that something is alive and moving in the skin has been presented to dermatologists and, to a lesser extent, psychiatrists for many years. It has attracted a ready psychodynamic explanation based on the concept of somatisation of emotional experience, and taking into account the symbolic function of the target organ.

“The good doctor can no longer be content without this knowledge – that his object is not only to save a life, but also to make the life he saves worth living” (Vasicka et al, 1958). This concept was being put forward 30 years ago by an American doctor, Vasicka, and his colleagues working in a gynaecological tumour clinic.

The sensations produced were those of exquisite lightness and airiness … I expected to be lifted up and carried away by the first breeze … the walls of my frame were burst outward and tumbled into ruin, and without thinking what form I wore … I felt that I existed throughout a vast extent of space. The blood pulsed from my head, sped through uncounted leagues before it reached my extremities; the air drawn into my lungs expanded into seas of limpid ether, and the arch of my skull was broader than the vault of heaven … I was a mass of transparent jelly, and a confectioner poured me into a twisted mould. (Taylor, 1856)