CHRISTINE ANZIEU-PREMMEREUR

THE SKIN-EGO

The Skin-Ego: Dyadic Sensuality, Trauma in Infancy,

and Adult Narcissistic Issues
Christine Anzieu-Premmereur
The skin-ego is a metaphor created by the French psychoanalyst
Didier Anzieu to describe the process by which the infants emerging ego develops a container for psychic contents and achieves a secure feeling of well-being. The ego encloses the psychic apparatus
as the skin encloses the body. The ego becomes able to fix barriers
protecting the internal world and to screen exchanges with the id,
the superego, and the outside world. The skin-ego is an envelope
that contains thoughts and gives to thinking activity some limits,
continuity, and a protection against the instincts. The functions of
the skin-ego are to maintain thoughts, to contain ideas and affects,
to provide a protective shield, to register traces of primary communication with the outside world, to manage inter-sensorial correspondences, to individuate, to support sexual excitation, and to
recharge the libido. The skin-ego is the foundation of the container
contained relationship. An important part of psychoanalytic work
with borderline patients is the reconstruction of the earliest phases
of the skin-ego and their consequences for mental organization.

Didier Anzieu developed his own critical approach to the body

in psychoanalysis during the 1970s, at a time when in France
structuralism had put language at the center. He rehabilitated
the body and the role of early sensations, associating in an unusual way Bowlbys (1958) view of attachment and Freudian drive
theory. Skin contact, maternal touching and holding, all primitive
experiences, were described as having a fundamental role in the
development of the ego and linked to adult unconscious functioning. Associating sensuality with the drives, Didier Anzieu stressed
the role of containment of emotions and primitive experiences
as a priority for the content of fantasies. Containers of psychic
experience were described as essential for maintaining a capacity
for internal organization and fantasy. Psychic envelopes and for-

Psychoanalytic Review, 102(5), October 2015

2015 N.P.A.P.

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mal signifiers were subsequent elaborations of skin-ego theory in

which sensory traces of maternal care and quality of attachment
precede drive content.
The skin is the surface of the body that receives and creates
sensations that give the infant the sense of a constant unity of
contact with the mother. This process is fully associated with the
integration of a sense of self, and the role of the skin experience
is to offer a possibility of containment of body sensations and
disorganized emotions. Skin-to-skin contact with the motherif
constant enoughgives the helpless baby elementary secure forms
of meanings. The establishment of the Skin-Ego responds to the
need for a narcissistic envelope and creates, for the psychic apparatus, the assurance of a constant, certain, basic well-being (Anzieu, 1985, p. 41). Direct observation of mothers and newborns,
reports of psychoanalytic investigation during analytic therapy of
children, and psychoanalytic reconstruction with adult patients
suffering from fragile narcissism allowed Didier Anzieu to understand the early need for a narcissistic envelope as the primary step
for the psyche to operate within limits that create a sense of security and continuity. Anzieu followed neither Lacans view of the
ego as imaginary nor the ego-psychological view of the ego as autonomous. His starting point was the protective shield described
by Freud as the foundation of embodied self-organization. In his
Project for a Scientific Psychology, Freud (1895) defined the ego as
a container for the internal objects and as a barrier protecting
the inside. The skin-ego, as developed by Anzieu, is a representation of the boundary between the internal world and the environment. The skin-ego also plays a decisive role in understanding the
vulnerabilities of narcissistic patients and their treatment. Skinego dynamics present clinically in the play and replay between
the patientanalyst bi-personal fantasy field (Civitarese & Ferro,
2013) that reflects narcissistic issues in the first intersubjective encounter with the object.
A TOPOLOGICAL MODEL OF EMBODIED SUBJECTIVITY
The skin-ego is a metaphor used to account for the psychic skin
that in turn is based on the biological skin. The reflexive capacity
of the skin makes it an essential element of the psyche: The sur-

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face of the skin that envelops the whole body informs the subject
about external perception, as it also is a medium of exchange. If
the skin-ego is both screen and filter, it also is conduit and communicative envelope formed with the first exchanges between
mother and baby. The skin-ego is at once a function that includes
both the biological envelopment of the uterus protecting the developing fetus and the psychic function of the mothers mind that
provides constant capacity for devotion to the infants needs. The
baby integrates the sensations from body contact with the mother, providing a sense of unity and integrity of the body-self that
eventually will be differentiated from the external object.
The skin-ego is the capacity of the ego to present and represent itself through the sensory experiences of the skin. It is an
interface: I feel myself feeling, touch myself touching. Mother
baby interaction is a sensorial bath that gives rise to the fantasy
of a common symmetrical skin between mother and infant. Internalization of this envelope allows the childs psyche to contain
and transform sensations and emotions into images, affects, and
thoughts. This very specific envelope is a shield against external
stimulations, a filter that has an economical function of regulating the quantity of what is being perceived. The other side of the
same envelope, the internal one, keeps a record of what has been
experienced and contained. The two layers of this envelope, the
envelope of excitation and the envelope of communication, are
connected together, the first one selecting the quantity of what
is being perceived, the second one selecting the quality of this
same registration. Anzieu postulated, based on his experiences
with masochistic and borderline patients, the fantasy of a common skin with the mother at the beginning of the psychic life.
This skin merger is the basis for containing elementary sensations
and associated fantasies. The experience of premature separation
from the mother is represented by the fantasy of a flayed body,
the traumatic painful tearing of the common skin.
Skin in common with the mother is a representation of an early
dyadic closed system and provides the infant with protection, security, and containment, as well as with inscription of traces of
early pleasurable and nonpleasurable experiences. The skin-ego
functions as a boundary that holds together the primitive parts
of the personality, a view not only elaborated by Anzieu but also
found in the English Kleinian context, especially in the work of

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Esther Bick (1968). Maternal preoccupation gives the mother the

capacity to be fully attentive and identified with her baby as she
performs adequate actions to hold and contain her infant. In the
dyadic sensorial bath between mother and baby, skin-ego contact
functions as an auxiliary ego for the helpless baby. The skin-ego
is a mental image of which the Ego of the child makes use during early phases of its development to represent itself as an Ego
containing psychical contents, on the basis of its experience of
the surface of the body, wrote Anzieu (1985, p. 40). As the baby
develops and as integration of sense of self is in process, he or
she forms a more mature sense of his or her own body with the
skin as the limiting membrane. With introjection of the capacity
for containment, a sense of individuality emerges from the dyad.
With good-enough developmental process, the fantasy of a common skin is supplanted by a more demarcated individual skin-ego.
The baby then feels himself or herself as a tridimensional body.
For this to be achieved the fantasy of the shared skin has to be
renounced. Yet achievement of a more discrete skin-ego also can
be traumatic. As infant research has shown during the past thirty
years and as some psychoanalytic schools have debated, subjectivity in infancy is shaped through body experiences and in relation to exchanges with the caregiver. Early traumas are difficult to
observe, yet may interfere with the integrity of the skin-ego and
narcissistic stability.
MOTHERINFANT INTERACTIONS AND SKIN-EGO GENESIS
Touch is the first sense to develop in the embryo, and thus the
skin is the basic reference point for all the various sense data.
As touch is the only reflexive sense, it gives rise gradually to the
reflexivity of thought. The baby develops the fantasy of a skin in
common with the mother, a shared fluid surface of contact, and
an interface with the mother on one side and the baby on the
otheran illusion of reciprocal inclusion. This sensorial fantasy
of skin contiguity between mother and baby can also undergo
deformation. The common skin can appear too tight or too loose
or violently torn away, leading to sense of falling through space or
being engulfed in absence, that is, to pathologies of the skin-ego.
Early integration of a sense of oneself and the attendant capacity

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for autoeroticism depends on the motherbaby dyads creative

capacity. This being together is the creativity of a play of attunements, which is shaped by looking at each other with coherent rhythms, through smiling or laughing at the same time, for
example, and feeling as if there is a shared mind, a reverie of dual
union without distinction. These are dynamic moments that give
support to the childs experience of being oneself through body
sensations.
Freuds (1895) Project for a Scientific Psychology first addresses,
implicitly, the role of the mother as a protective shield against
stimuli, a function essential for maintaining the internal balance
in the childs psychic functioning as well as in stimulating pleasure
and desire. The stimulus barrier aspect of skin-ego function has
some commonalities with Damasios (1994) notion of background
body states or primordial representations He writes: The background sensation is continuous, although one may hardly notice
it, since it represents not a specific part of anything in the body
but rather an overall state of most everything in it. . . . My idea
is that images of body state are in the background, usually unattended but ready to spring forward (p. 234). In this formative
epoch of body sensibility there is a mutual inclusion of bodies,
interwoven on the level of sense and in fantasy, between mother
and child. An infant under his or her mothers care receives both
stimulation and communication, and through this process establishes a body-ego responsive to the need for a narcissistic envelope
that creates for the psychic apparatus the assurance of a constant,
certain, and basic lived experience of well-being. The body-ego is
at first a body-in-relation.
Most developmental psychologists regard the caregiver as the
outer half of the self. Spitz (1945) spoke of the mother as the
auxiliary ego, the symbiotic half of the motherchild unit. The
mothers body, the breast, and milk are experienced by the infant
as his or her own body. There is an integrated sensory progression
to this experience of early inclusive yet emerging alterity. First, in
the recognition of the mother, is smell, then the gaze, and with
the gaze attunement to the mothers face in harmony with the
rhythm and sound of her voice, added to which is the quality of
her holding, the supple yet defined presence of her skin, and the
tenderness of her touchingall these sensations, proprioceptions,
and perceptions are part of the infants self. A few months later in

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development, the mothers hair and nose, then her glasses, jewelry, and scarf become parts of the body-ego; as detachable parts of
the body, they could eventually also become transitional objects.
At first, internal sensations are a source for the infant of experiences of repetition, and through repetition, continuity. Consider
the fate of milk, the first pleasure in the mouth, the warmth in the
belly, maybe weird colicky pain-assault, finally, relief and relaxation with expulsion of fecesthis whole long journey from ingestion to digestion shapes continuities in being (Winnicott, 1945).
The babys body is an interplay of different bodies: the body
that feels inside sensations, ingesting and expelling, full with liquids; the extended surface body, enveloped by the skin that is
the first container yet interrupted by holes that are the sensitive
areas that create libidinal pleasurethe mouth, the anal-ureteral
zone, and the genitals; the muscular body, solid and attached to
the skeleton, that gives the sense of agency and will offer the first
defenses; and the visceral body, which is the center of the psychosomatic organization. All these bodies are integrated during development, when the child will discover their unity in front of the
mirror. The importance of the body in the process of becoming
myself is clear when we observe pathology. In her work with autistic children, Tustin (1986) described children who [felt] skinless and disembodied. The skin has been replaced by the armor
of autistic practices which help to feel protected from the
terrors of falling, of dissolving, of spilling (p. 301). During
therapy, their body image begins to feel more substantial and
intact [and] they begin to feel that they have an inner structure
(p. 235).
Bob is a three-month-old baby whose mother had a psychotic
reaction to his birth. There are moments when Bobs mother is
nice and attentive, close to his body and warm, then suddenly,
when invaded by a persecutory delusion, she becomes avoidant or
intrusive. Bob smiles at her when his mother is in a nondeluded
state, but screams and becomes disorganized when she is inside a
persecutory force field. At three months he is separated from his
mother, who is replaced by a nurse who cares for him. Two days
post-separation, Bobs body is covered with eczema. Bob stops
smiling and does not eat. When mother and baby are reunited
in a special psychiatric ward and he is then close to his mothers
body, his eczema disappears, but Bob averts his gaze and closes

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his eyes to avoid the mothers unpredictable gaze, while his body
becomes stiff and rigid as if frozen. After a few days together,
the mother desired to give Bob a skin massage, during which he
started to suck his thumb while looking at her.
The mothers emotional response to her babys gaze gives the
child the sense of his or her own experience. Being seen is crucial, as it is through the attentive gaze of the mother that the child
identifies and comes to know both what he or she feels and to own
his or her experience, affirming the observation that the precursor of the mirror is the mothers face (Winnicott, 1971, p. 112).
Current research on motherbaby interaction demonstrates that
the mother reflects her babys experience not only through facial
expressions but also through all other modalities of communication (Beebe, 2005). The mirroring function is conveyed not only
through the face of the mother but also through her body contact and the quality of the holding, which convey to her baby the
sense of what the baby is experiencing. Failure of embodied mirroring responsiveness exemplifies the centrality of the skin-ego
as a stimulus barrier through which primordial representations
are integrated. Skin-ego theory demonstrates the consequences
of failure in the bodily mirroring response.
Paul is fifteen-month-old tiny boy with a very unbalanced walk.
He becomes confused and disconnected from others as soon as
he is away from his mothers body. He does not talk and does not
exchange any look with others. It is as if his body is not organized
when his mother is not close to him. He can speak and play only
when she is attuned to him, as otherwise the mother is too depressed to attend to Pauls needs. When I started talking to him
while caressing his back, Paul could be reassembled, and from this
position he was able to walk with ease and look for a toy. At other
moments Paul could interact with me and play, but only when
leaning on his mothers body with his mouth full with a piece of
bread. The experience of Paul further exemplifies the role of the
skin-ego as a containing object, a theme found not only in the
work of Didier Anzieu but also in the infant observation studies
of Bick (1968):
The need for a containing object would seem, in the infantile
un-integrated state, to produce a frantic search for an objecta
light, a voice, a smell, or other sensual objectwhich can hold

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the attention and thereby be experienced, momentarily at least,

as holding the parts of the personality together. The optimal
object is the nipple in the mouth, together with the holding and
talking and familiar smelling mother. . . . This containing object
is experienced concretely as a skin. (p. 484)

Children who have rocked for months in their first and second
year in order to hold themselves together through self-stimulation
are brought to the child analyst for help later in latency with significant motor disturbancestics, hyperactivity, and impulsivity
and with intense fears of object loss that also date from infancy.
Ego weakness is linked to problems in establishing object constancy (Kernberg, 1976). The child who has not achieved object constancy cannot consistently evoke the image of the mother and as
a result of this incapacity remains perceptually reliant upon her.
Children defined by such lack do not relate to persons as a whole
but rather in terms of part-objects such as the breast. Children
who cannot sustain the presence of a vital inner representation
of the mother are those who often engage in violent self-soothing
activities as a consequence of not being able to recruit ongoing
pleasurable interactions with their caregiver. These children use
their body to create a sort of muscular armor or a rigidly uptight
body that is precociously independent while seeking self-stimulation and self-quieting in repetitive and often impactful ways. Body
pleasure further enriches vital internal representations in childhood since through infantile sexuality and autoeroticism the child
develops organizing figurations of self-cohesion. When genital
adult sexuality has been achieved, the fantasy world is supported
by the quality of object relations.
When deferred action (aprs-coup) gives the adult retroactive
sexual meaning to the childhood events, the narcissistic issues
that the patient as a child has faced will sponsor in the adult a
sense of often-tormenting emptiness. Pervasive addictive strategies that are endemic to contemporary social life are often derivative of failure in establishing coherent early representations
and secure skin-ego contiguity. One further manifestation of an
unstable internal world organized around introjection of a goodenough maternal presence is the use of erotic cyber-images. Such
images function as a virtual excitable second skin, one that stimulates fantasy as a predominant mode of relational engagement.

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These early narcissistic failures can subsequently be commemorated in sexual enactments.

NEUROSCIENCE: MIRRORING AND TOUCH
Early failure in representation of maternal consistency and the
quality of skin-ego formation has important implications for clinical interventions specific to the particular patterns of mother and
infant distresses. Such strategies also take into account the role
of neuroplasticity in the ability of dyads to repair their misattunement with the outcome that psychotherapeutic interventions can
alter developmental trajectory. It is in this context that we might
think of Freuds formulation of the body-ego as a body-in-relation
ego. Current neuroscience findings highlight the role of the dyad
in the genesis and transmission of embodied consciousness. Neural mechanisms mediate pathways through which bodily sensations are mentalized via interpersonal exchange to form the foundation of the self. Skin-to-skin contact is associated with oxytocin
release and has a positive impact on motherinfant connection
when secure attachment is otherwise at risk. Between a premature
infant and a traumatized mother it has been shown that touch and
physical proximity diminish negative emotions while promoting
positive interaction. Mothers with an insecure and dismissing pattern of attachment have impaired peripheral and central oxytocin
production that in turn reduces activation of reward processing
regions in the brain when presented with facial cues from their
infant.
Capacity for imitation in a dyad as mediated through the mirror neuron system has predictive power and shows evidence of
plasticity in the brain that will reinforce the validity of early interventions. Neonatal imitation also is possible by virtue of the role
mirror neuron activation plays in the motherbaby bond. There
is, as a result, a neural basis of empathic communication between
mother and infant, the outcome of which also is the transmission
of this essential social skill. Shared neural activation patterns and
the mechanism of embodied simulation constitute a foundational
biological basis for understanding anothers mind. The implications of this perspective are highly relevant for understanding attunement, empathy, unconscious communication, and projective

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identification. Microanalysis of motherinfant face-to-face communication modalities at four months of age that consider the
role of attention, affect, touch, and spatial orientation predicted
insecure attachment outcomes at twelve months old, particularly
resistant and disorganized attachment patterns (Beebe, 2006).
These findings are hypothesized to be the outcome of perturbation in mirror neuron dynamics between mother and baby. Cumulative failures of maternal affective attunement to distressed
infants compromise affect regulation and emergent agency on
the part of the infant. As a result of attunement failure, the infant
senses not being known by the mother, invoking, as a result, states
of confusion, which persist as a failure of integration for the developing person.
THE FUNCTIONS OF THE SKIN-EGO
There are eight functions of the skin-ego. These are maintenance,
containment, protection, individuation, intersensoriality, sexualization, libidinal recharging, and inscription. Anzieu suggests
that when these functions are integrated and develop without significant disturbance, the capacity for thinking as a higher-order
ego function follows.
Maintenance is the quality of a solid, reliable physical support
interiorized by the baby as part of his or her own body and is associated with the stability of the narcissistic foundation of the self.
Through the skin-ego function of maintenance, body sensations
are held together physically and psychically, and in this way the
skin-ego maintains the psyche in a functional state, at least during
waking life. Related to the maintenance function of the skin-ego
is the concept of holding (Winnicott, 1945) and the hypothesis of
the background object of primary identification (Grotstein, 1981).
The function of maintenance is revealed through the impact of its
absence. Children in a depressive maternal field or subject to loss
in the first year of life have a tendency to play at falling down on
their back, or they may make dolls fall down without support or
protection. For example, a fourteen-month-old baby was compulsively pulling his hair in a helpless search for self-soothing while
experiencing the loss of his mother, who was emotionally unavailable. Therapy with baby and mother conjointly provided a fram-

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ing background support in which this symptom disappeared, to

be replaced by an easeful autoeroticism as long as touching and
caressing his back was provided.
Containment is about handling the body. Babies are touched,
moved, washed, and rocked, and they feel their body as a sac that
contains bodily contacts as well as a surface that feels pleasure
and pain. This sense of somatic containment is associated with
the mothers correlative capacity for emotional containment and
transformation through reverie as described by Bion (1970).
When maintenance and containment of the skin-ego cannot be
built, the self is damaged, either because the baby has a very low
level of tolerance or because the environment fails in its role as
support, resulting in primitive agonies that impede the process of
forming representations. Babies who have avoidant and defensively withdrawn reactions to their psychically unavailable mothers
are those who as toddlers will suffer from disorganizing separation anxieties. For the baby, in his or her confusion, the absent
mother is a forever-dead mother. Maternal absence marks indelibly the formation of the vulnerable self. There is no invested
memory in body feeling that otherwise could sustain a sense of an
alive and vital self. For example, an adult patient, who as a young
child had to travel long flights by herself to meet her divorced
father, remembered the dreadful sensations of total emptiness
when losing the memory of her mother: My mother was dead
forever and the feeling of a cold empty space without any possibility to form an image of her made me crazy, frozen and totally
disconnected from my body. For days, I couldnt walk, talk, think
or dream.
Protection is a barrier against external intrusion. The skin-ego
protects against trauma. The mothers skin and body are offered
for use as a shield against intrusive or excessive stimuli. The introjection of this protective capacity provides a source of security.
The failure of this function kindles early trauma and results in
primitive defensive organization. Fraiberg (1982) describes avoidant babies who never turn to their mother and who scream in
distress when in need. When the mother is not a source of protection, Fraiberg observed a correlative freezing immobilization
on the part of their infants, as such immobilization was the only
way to disengage from otherwise intolerable body feelings of exposure to a premature absence.

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Individuation gives a sense of identity and individuality. Skin

boundaries are associated with psychic barriers that eventually
allow for having a skin of ones own, differentiated from the
mothers skin. This development initiates emergent true-self capacity. Maternal dysfunction, however, can compromise this development. Second-skin defense, as described by Bick (1968),
represents a defensive organization against this failure of secure
provision that impedes generative separationindividuation.
Bick describes a patient who moved between two states of selforganization. In the sack of apples state, the patient was touchy,
vain, in need of constant attention and praise, easily bruised and
constantly expecting catastrophe. In the hippopotamus state,
the patient was aggressive, tyrannical, scathing, and relentless in
following his own way. Both states were related to a second-skin
type of organization and dominated by projective identification.
The hippopotamus skin reflected the objects skin, inside of
which the patient existed, while the sack of apples easily bruised
thin-skinned state represented parts of the self that were inside
this insensitive object. Patients with disturbed first-skin formation
reveal through analytic reconstruction fundamental disturbances
in internal self-organization, even if their parents did not observe
these states when the patients were infants. This faulty skin-formation produces a general fragility in later integration and organization. Faulty skin-formation expresses a primary deficit and is
not a function of regression. It manifests in states of unintegration of the body, expressed through posture, motility, and correlative mental functions such as communication. The second skin
phenomenon is apparent through a type of embodiment that is
expressed as a muscular shell or through a corresponding verbal
muscularity.
As an illustration: Ellen is a three-year-old girl who has been
expelled from preschool because she could not stand her mother
leaving her. When separated from her mother, Ellen would at
times scream for more than thirty minutes, bite other children,
lick the teachers shoes, and withdraw from any social interaction.
When I met Ellen, I encountered a beautiful little girl who sat
on her mothers lap in a seductive and provocative manner, yet
who could not separate. After many sessions with Ellen while the
mother was in the room and following the beginning of some pretend play, I asked Ellen to come with me into another space but

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to take something of the mother (her scarf or keys or phone) with

her. Ellen did so and now cried only for five minutes, after which
we were able to resume playing. I talked to Ellen about her feeling
of losing a part of her self. She then played at falling down repeatedly, being like a piece of fabric without any shape or bone structure. I imitated her self-collapse with a doll that I put on my lap
but that I also dressed to convey a sense of natural aliveness. In
the next session, I had to tie up Ellen very tight with a rope. She
then was calm and contained. Ellen said that this was the only way
for her to be sure she would not lose her limbs. In the next session
I had to use a lot of tape so that both of us might stick together
while we played at sleeping together. Ellen then started to build
enveloping walls with blocks to protect the dolls; she said that
this protected her against the feeling of vertigo. Ellen then drew
big circles that were included in bigger circles. I commented on
her good feeling at being enveloped by her mommys arms and
belly. A few weeks later she added a second skin to the animals.
Ellen drew them carefully with a double line of bold color to fully
envelope the body, while saying emphatically: This is me! Ellen
could talk about her fear that her body might dissolve into water
and disappear forever as well as her fear that her back would be
lost when she walked inside the school and saw her mother disappear. Subsequently, Ellen stopped hurting herself by falling down
at any moment when walking or running. While therapy with Ellen conveys something of the process of reparative individuation,
it also reveals the profound degree of disorganization associated
initially with losing contact with her mother, who in herself was
very fragile and unavailable and who had memories of cutting
herself in adolescence as an act of rage against her own absent
mother.
Intersensoriality, the fifth function of the skin-ego, refers to
when the skin connects up the bodys sensations of various sorts
and makes them stand out as figures against the original background (Anzieu, 1985, p. 103). Different sensations can be experienced as chaotic and sometimes frightening, as is the case for
infants dealing with sensory issues, such as hypersensitivity and
sensory-integration disturbances. The skin-ego coordinates different sensations and gives a feeling of unity that decreases the otherwise overwhelming danger of stimuli. The skin-ego associatively
links auditory, olfactory, gustatory, and visual sensations as well

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as sounds, smells, and tastes within the continuum of the psychic

envelope. Anzieu (1987) uses the metaphor of the skin of an onion to describe the intersensorial integration of multiple sensory
skins (the auditory skin and the tactile skin as well as the olfactory
and gustatory skins) into a psychic envelope.
Sexualization is the part of the skin-ego that serves as a support
for the drives. Skin contact is the source of pleasure and stimulation of the erogenous zones. We know from Laplanche (1997)
that the mothers unconscious fantasies will play a role in the
childs sexual organization. The capacity for autoeroticism is essential for the ability to develop a relation with the absent object
and to evolve a mature sexuality. The consequences of the early
formation of these representations can be decisive. If the child
has developed a structure to contain the representations and a
capacity for figuration, then analytic intervention, if needed, will
focus on the content of the childhood fantasies and their aprs
coup meaning.
Libidinal Recharging involves the skin-ego synthesizing stimuli and facilitating their regulation in order to contain states of
over- or under-stimulation. The anxiety associated with being disorganized by chaotic stimuli can lead to discharge into the body
through arousal in excess of meaning, as can be seen frequently in
childhood behavioral issues or in psychosomatics reactions to the
exciting presence or absence of the mother. In contrast, children
deprived of libidinal refueling often develop depressive feelings
and loss of vitality. An adult patient described herself as a crab
without shell, empty and lifeless, often irritated through oversensitivity to contact with others and full of hatred toward her mother who did not protect her against early hypersexualization. The
object of early attachment is important by virtue of its stimulating
action, which for the child also must be introjected if the capacity
for growing and enriching libidinal cathexis is to develop. When
parents forbid the toddler to touch some objects and to repress
his or her impulses, they help to organize the drives and build the
process of representing the absent satisfying object. This is an essential step for the formation of the Oedipus complex.
Inscription is the last function of the skin-ego and one that is
essential for the development of thinking capacity through use
of memory traces of early experiences that have been elaborated
through symbolization. Registration of sensory traces and the in-

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formation they provide about the external world is reinforced by

the environment that presents objects (Winnicott, 1945). The
Skin Ego is the original parchment which preserves, like a palimpsest, the erased, scratched-out, written-over, first outlines of an
original pre-verbal writing made up of traces upon the skin (Anzieu, 1985, p. 105). This inscriptive function of the skin-ego has
some similarities with Aulagniers (1975) notion of pictogram
and its formation in relation to psychic primal processes. Some
inscriptions are sources of pain or shame. Eczema rash, for example, encodes premature detachment from the mothers body.
Tattoos, scarifications, and other skin inscriptions signal search
for continuity with the object when anxious over losing traces of
contact. The skin-ego develops as a thinking ego through serving
as barrier, filter, and surface of meaning. In Anzieus theory, sensations are as fundamental as sexuality. There are, he suggested,
two sides to the human personone expressed through sensoriality, the other through sexuality. Sensation informs us about the
state of the body and is a pathway to awareness. Sensation brings
poignancy and vividness to experience, shaping sensoraility into
an aesthetic sense. All sensationseven brutal onesfuel the sensory feeling of being alive. Anzieu, aligning more in this regard
with Rousseau than with Descartes, frequently summarized his
view of the primary import of sensory experience in the statement I feel, therefore I am, which he said at times with a playful
twinkle.
PSYCHIC ENVELOPES AND ANALYTIC TECHNIQUE
According to Anzieu, lack of separation between the envelope of
stimulation and the envelope of communication creates pathology due to an absence of transitional space and the consequent
inability to engage in fantasy formation. This failure of transitional space enrichment and correlated collapse of fantasmatization results in concrete thinking (la pense opratoire), a style of
communication that is both emotionless and lacking in imagination (Marty, 1968). In the case of such psychosomatic formation,
Anzieu speculates that the psychic envelope has been reduced
to a single archaic layer in which mentalization takes the place
of thinking. This mode of being can result from a depressed or

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CHRISTINE ANZIEU-PREMMEREUR

mournful mother not being able to transform the babys experiences in such a way that they are available for use (mental elaboration) by the infant. Failure of presentation results in damaged
capacity for representation, a view that also has been elaborated
in the work of Green (1972), especially his clinical concept of
the dead mother. In Les Enveloppes Psychiques (Psychic Envelopes)
Anzieu describes the concept of the signifiant formel, the formal
signifier (Anzieu, 1987). Formal signifiers, in contrast to linguistic
signifiers, represent the psychic properties of space and express
forms of the containing function of the mind. Impressions, sensations, and ordeals that are at once intense and too early to be put
into words constitute the elements out of which formal signifiers
are built. Their identification can be useful to the psychoanalyst
for understanding alterations in the construction of the ego.
Children give meaning to their bodily feelings, which come to
be identified later as affects after the mother first has given meaning to their experiences. Babies and toddlers communicate with
gestures and expressions what they feel with pleasure or displeasure and what places them at risk for disorganization and chaos.
Psychoanalysts who participated in home infant-observation programs, following the Tavistock Clinic model, often reported their
own disturbed bodily experience when the baby is taking a bath,
such as feeling dizzy, or their distress and disorientation when a
young babys head was not well held or their intense feeling of
pleasure and empowerment when the child stands up for the first
time. A four-year-old child who I saw in psychotherapy with his
borderline and often distressed mother first presented as a floppy
and limp baby when held in her arms. This boy spoke of how distressed he felt when forced to take bath, as in those moments he
experienced his mothers body as melting like powdered sugar.
His need for firm and secure holding was expressed clearly in his
drawings of animals with multiple skins.
Formal signifiers encode sensory traces of early failures in maternal care that result in trauma for the child. These moments of
inscription subsequently may be represented in such expressions
as a bag has a hole in it or a skin which shrinks. Further examples of formal signifiers in which a spatial dimension is activated
or undergoes potential transformation include such dimensions
as a vertical axis is reversed; a support collapses; a hole sucks
in; a solid body is crossed; a gaseous body explodes; an orifice

THE SKIN-EGO 675

opens and closes; a limit interposes; a retreating object abandons

me (Anzieu, 1987). Anzieus classification of formal signifiers
range from those undergoing irreversible modification (a hole
sucks in) to those showing some reversibility (a cavity is emptied
and is replenished) to those indicating some individuation (a
boundary intervenes) to, finally, those that give rise to phantasy
scenarios built around linguistic signifiers (an object persecutes
me). This typology finds some homology with what are called
demarcation signifiers (Rosolato, cited in Anzieu, 1987).
Attunement on the part of the analyst to formal signifiers expressing psychic envelope deformation expands the repertoire
of empathic intervention to include skin-ego pathologies and
their formative developmental traumas. The patient who cannot express with words the neglectfulness or failures of the early
environment will signify those defects and their consequences
through the sensate body. The ensuing spectrum of formal significations suggests that this mode of communicative evocation
would be only partially and not necessarily primarily understood
if viewed as an expression of sexual phantasy. Working on the
level of formal signification, the analysts therapeutic intention is
not to provide a corrective emotional experience for the deprived
internal baby body through tactile or other tangible provision.
Through understanding skin-ego deformations as sets of formal
signifiers, the analyst transforms body signals from the patient
into symbolic indices that assist the patient in thinking about the
skin-ego disturbances. In this way, the patient communicates not
only his or her immediate sensations and body experiences, but
also begins to talk and think about them. When a mother cannot
echo the babys experiences, no meaning develops. The capacity
for experiencing the feeling-self is developed though the mother
experiencing in her feeling-self what the child lives. In a similar
way the analyst holds the patient with his or her collation of attention, preoccupation, and active intervention, and through these
processes provides for the patient the experience of being contained.
Echoing the patients archaic experiences, the analyst forms
a circular relation where perceptions and sensations are shared,
managed, and then expressed through words. As Sechaud (2007)
said, psychoanalysis is a lively skin for thoughts (p. 23). In Anzieus view, the two foundational analytical rulesthe rule of

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CHRISTINE ANZIEU-PREMMEREUR

abstinence and the rule of free associationsexpress two layers

of the psychic envelope: the inner side of the protective shield
and the outside of inscription. The progressive differentiation of
these two layers allows the neurotic to use the classic framework.
Disturbance in establishing these layers requires an adjustment
in the analytic frame in order to adapt to the patients level of
symbolization. Anzieu spoke of the adaptive need required in the
psychoanalytic frame to meet the psychic sensitivities of those
with skin-ego vulnerabilities in a transitional psychoanalysis, a
view also shared by Winnicott (1945), who emphasized the importance of discerning the level of the patients ego need as a condition for understanding appropriate analytic provision. What
the patient no longer tolerates in the usual analytical framework
reveals the early impediment of the environment which marked
his Self. In this case, a new framework must be created by the two
parties, the psychoanalyst and the patient, in between the traditional psychoanalytical framework, which remains the goal of the
analyst, and the auxiliary-framework, precisely adapted in order
to compensate the lacks of the patient, who claims it explicitly or
implicitly (Anzieu, 1979, p. 203). It is fundamental for the ego to
have a skin that is consistent, with safe limits and a flexible structure. Grounded in these foundational capacities, a thinking ego
emerges that can speak and think associatively.
Those for whom a deficit in skin-ego integrity is primary cannot make use of a classic analytic frame that presupposes a defined yet flexible self that can think with some degree of freedom.
Those functioning within the more archaic register require on the
part of the analyst another level of attunement. For Anzieu, the
analytic frame also can become a kind of skin-ego, a protective
shield against trauma. While Freud (1895) first viewed trauma
from an economic perspective (an effraction of the stimulus barrier), Anzieu, in recognizing that early childhood traumas are
the result of flaws in the caregivers psychic envelopes, adopted a
more topological model. From this perspective trauma must first
be elaborated through reconstruction on the part of the analyst
so that the ego may then become free to exercise its capacity for
synthesis, integration, and reflective thought.
Anzieu (1987) exemplifies this point in his discussion of the
first analytic hour with a thirty-year-old woman who consulted
him after a suicidal attempt. She was silent, holding her arms up

THE SKIN-EGO 677

in the air, looking very anxious. She explained that her skin was
getting narrow, that she was feeling terrible and losing her identity. As the patient also spoke of an obsessive sense of being an old
shriveled woman, Anzieu understood this communication as expressing a fantasy of the skin separating from the body. She asked
Anzieu if he saw her skin shrinking. He said no, that, instead,
he saw her as a whole person. She then quieted, yet elaborated
her view: Its something horrible, I feel like a peau de chagrin a
shagreen [a piece of uncured leather]. My skin, she reiterated,
is disappearing (p. 3). In speaking of a peau de chagrin and
her sense of disappearing skin, the patient is making reference
to an 1831 novel by Balzac, in which the main character is given
a piece of untanned skin that fulfills every wish; however, with
each wish fulfilled, the skin shrinks and physical energy becomes
depleted. Anzieu then offered this interpretation: This piece of
skin is from your mother and you need to be separated from it.
The patient cried: I know I have to go away from her, but I dont
have a skin anymore. I am going to dissolve into air (p. 3).
Anzieu, feeling in that moment overwhelmed, silently echoed
an internal correlate to the patients experience. He then stated:
You need to change your mothers skin for your own skin (p.
3), in response to which the patient described experiencing her
body without any limit, as if she were floating in space. Anzieu,
feeling more anxious, said: You are like a snake that sheds its
skin; it leaves its former skin (p. 3), A shift in inner organization
began to emerge at this point. Now thinking of her mother as poisonous, the patient indicated feeling relieved and began to reflect
on the connection between her feeling of disappearance and her
suicidal attempt. The patient then remembered her mother reproaching her for the mothers changed and worn-out body after
giving birth. Her mother, she said, always told the patient that she
never wanted a child. When thinking of this, the patient felt as if
she were like water, fluid and without discrete boundary. Yet she
also could in that moment recognize that her mother would be
very sad if she, the patient, were in fact dead.
This case illustrates some of the sufferings that follow from
skin-ego disorders and their narcissistic consequences. Anzieu
(1985) offers this summary:

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CHRISTINE ANZIEU-PREMMEREUR

The patient is suffering from an absence of borders or limits. He

is uncertain of the frontiers between the psychical and bodily
Egos, between the reality Ego and the ideal Ego, between what
belongs to the Self and what to others; he experiences sudden
fluctuations of these frontiers accompanied by descent into depression, is unable to differentiate erogenous zones, confuses
pleasant experiences with painful ones, and cannot distinguish
between drives, which leads him to experience the manifestation
of a drive not as desire but as violence. The patient is also vulnerable to narcissistic wounds through the weakness of the psychical
envelope, and experiences a diffuse sense of ill-being, a feeling of
not being inside his life, of watching the functioning of his body
and mind from the outside, of being the spectator of something
which is and at the same time is not his own experience. (p. 123)

While narcissistic deficit is at the center of treatment for highly

vulnerable patients, it also is part of the analysis of any patient.
In instances of pervasive narcissistic vulnerability there is impairment of the reflexive function within the internal mirror of the
ego (Roussillon, 2011). The experience of oneself in relation to
the object cannot be represented, often to the extent that the
whole capacity for representation has been damaged (AnzieuPremmereur, 2013). Emptiness and incapacity with respect to the
formation of associations are in these instances primary modes
of self-presentation. In the transference, envy, shame, and rage
define perception and transaction. The patient oscillates between
rigidity and deficit. The two sources of narcissistic supportthe
body and the objectare activated in the transference. In that we
feel ourselves as we have been felt and see ourselves as we have
been seen, the analysis of such patients manifests traces of primitive development and early linking to the object. As a result, the
patient has a tendency to use the analyst as part of himself or herself, and in so doing paradoxically induces in the analyst those affects and ego defects that had not been tolerated or integrated in
the early years of the patients life. Through the countertransference the analyst witnesses and experientially discovers traumatic
links to the object and body not otherwise accessible to memory.
Anzieu (1979) spoke of this form of resonant knowing of early
trauma through the countertransference as an aspect of paradoxical transference. It is from this vulnerable position of inscribed
impact that the analyst, often through painful feelings, imagina-

THE SKIN-EGO 679

tively infers early traumatic formations in the patients history.

The evoked countertransference reveals what is otherwise occluded through the negating organization of narcissistic defenses and
their destructive impact.
In this way, the analyst offers the patient understanding through
the integrative facilitation of reconstructions, not through interpretations. The analyst, in working with persons with determinant skin-ego pathologies can most fruitfully communicate countertransference discoveries through the creative use of metaphor
as a concise and condensed way to convey understanding. It is
this style of intervention that was common for Anzieu, one also
shared with Andr Green, who for this reason, among others,
spoke of Didier Anzieu as his imaginary twin. Both recognized
the persecutory effects of silence on such patients while also emphasizing the analysts background attention as a source of nonverbal contact.
Those persons who Didier Anzieu cared for with great facility were those suffering from lack of limits and uncertainty regarding the boundaries between psychic and body ego as well as
between the conscious ego and ego ideal. The narcissistic and
borderline vulnerability of such patients also results in confusion
with respect to the differentiation between erogenous zones, uncertain if they are sources of pain or pleasure. Anzieu met these
patients at the fundamental point of their suffering through his
understanding of the fundamental role of sensations and sensuality in the motherbaby attachment dynamic, a view that was
in part also informed by researches on early motherinfant interactions. Complementing libidinal theory with its emphasis on
satisfaction from an exciting object, Anzieu described another
drive whose origin is expressed in signals received through the
quality of touch, the solidity of holding, the softness and rhythm
of contact. Originating in early interactions with the body and its
surface, the skin, this drive is the starting point of primary narcissism and develops through the double envelope of stimulation
excitement and of communication. In working with vulnerable
patients containment, continuity, and integration are priorities.
A secure experience of the skin-ego is the primary condition for
feeling alive. Didier Anzieu, in his concept of the skin-ego, has
given us a way to understand what is necessary to both feel alive
and to thrive.

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CHRISTINE ANZIEU-PREMMEREUR

REFERENCES
Anzieu, D. (1979). La dmarche de lanalyse transitionnelle en psychanalyse
individuelle: Avec des commentaires sur lobservation de la cure de Mme
Oggi [The approach of transitional analysis in individual psychoanalysis:
With comments on the observation of the treatment of Mme. Oggi]. In
R. Kas, ed., Crise, rupture et dpassement [Depression, break and excess]
(pp. 186-219). Paris: Dunod.
_______ (1985). The skin ego (C. Turner, Trans.). New Haven, Conn.: Yale
University Press, 1989.
_______ (1987). Psychic envelopes. London: Karnac Books, 1990.
Anzieu-Premmereur, C. (2009). The dead father figure and the symbolization
process. In L. Kalinich & S. Taylor, The dead father: A psychoanalytic inquiry
(pp. 133-144). New York: Routledge,
_______ (2013). The process of representation in early childhood. In H.
Levine, G. Reed, & D. Scarfone, eds., Unrepresented to represented mental
states (pp. 240-254). London: Routledge.
Aulagnier, P. (1975). The violence of interpretation: From pictogram to statement (A Sheridan, trans.). Philadelphia: Brunner-Routledge, 2001.
Beebe, B. (2005). Mother-infant research informs mother-infant treatment.
Psychoanal. Study of the Child, 60:7-46.
_______ (2006). Co-constructing mother-infant distress in face-to-face interactions: Contributions of microanalysis. Infant Observation, 9(2):151-164.
Bick, E. (1968). The experience of the skin in early objects relations. Internat.
J. Psycho-Anal., 49:484-486.
Bion, W. R. (1970). Attention and interpretation. In Seven servants. New York:
Aronson.
Bowlby, J. (1958). The nature of the childs tie to his mother. Internat. J.
Psycho-Anal., 39:350-373.
Civitarese, G., & Ferro, A. (2013). The meaning and use of metaphor in
analytic field theory. Psychoanal. Inq., 33:190-209.
Damasio, A. R. (1994). Descartes error: Emotion, reason and the human brain.
New York: Putnam.
Fraiberg, S. (1982). Pathological defenses in infancy. Psychoanal Quart.,
51:612-635.
Freud, S. (1895). Project for a scientific psychology. In J. Strachey, ed. and
trans., The standard edition of the complete psychological works of Sigmund
Freud, 24 vols. London: Hogarth Press, 1953-1974. 1:281-391.
Green, A. (1972). On private madness. New York: International Universities
Press.
Grotstein, J. S. (1981). Splitting and projective identification. New York: Aronson.
Kernberg, O. F. (1976). Object relations theory and clinical psychoanalysis. New
York: Aronson.
Laplanche, J. (1997). The theory of seduction and the problem of the Other.
Internat. J. Psycho-Anal., 78:653-666.
Marty, P. (1968). Essential depression. In Reading French psychoanalysis (S.
F. D. Birksted-Breen, &A. Gibeault, eds.; pp. 458-462). New York: Routledge/Taylor & Francis,2010.

THE SKIN-EGO 681

Roussillon, R. (2011). Primitive agony and its symbolization. London: Karnac
Books.
Sechaud, E. (2007). La pense de Didier Anzieu. Carnet/Psy, (117):18-23.
Spitz, R. A. (1945). HospitalismAn inquiry into the genesis of psychiatric
conditions in early childhood. Psychoanal. Study of the Child, 1:53-74.
Tustin, F. (1986). Autistic barriers in neurotic patients. London: Routledge &
Kegan Paul.
Winnicott, D. W. (1945). Primitive emotional development. In Through paediatrics to psycho-analysis (pp. 145-156). New York: Basic Books, 1975.
_______ (1971). Mirror-role of mother and family in child development. In
Playing and reality (pp. 101-111). London: Penguin Books.

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