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Specificities of Mental Functioning and Referential Process in Body Dysmorphic Disorder: A Single Case Study Using the Psychodynamic Diagnostic Manual (PDM-2)

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Abstract

This study aimed to accurately diagnose a patient with body dysmorphic disorder (BDD) and explore challenges to symbolization in the early and middle stages of psychotherapy through an analysis of language used by both therapist and patient. The patient was assessed using the Psychodynamic Chart in the Psychodynamic Diagnostic Manual and the Referential Process language measures, which were applied to the early and middle treatment sessions. At the beginning of treatment, the patient presented with comorbid somatizing and schizoid personality disorders, and strong obsessive and anxiety-avoidant traits. He displayed significant impairments in capacity for mentalization; affective range; communication and understanding; self-esteem regulation; and relational intimacy. The patient met criteria for severe BDD. His speech showed a markedly abstract and intellectualized linguistic style that indicated great difficulty in connecting emotional experience to images and words. The therapist’s interventions were adapted to this style and were characterized by continuous prompts and suggestions aimed at linking elements and supporting a symbolizing process in order to integrate emotional activation in narratives. This therapeutic action, which we labeled “aided symbolization” promoted a slow but significant process of change with improvement in overall mental functioning. The clinical implications of these results are discussed.

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Notes

  1. The notion of aided symbolization was developed by Attà Negri to highlight narratives that depend on the therapist’s active engagement to maintain the symbolic process. This contrasts with the more frequently observed instances where patients autonomously narrate experiences and sustain the level of symbolization without requiring direct therapist intervention.

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Author information

Authors and Affiliations

  1. School of Medicine, Department of Psychiatry, Yale University, New Haven, CT, USA

    Christopher Christian

  2. Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy

    Alice Fiorini Bincoletto, Rachele Mariani, Vittorio Lingiardi & Annalisa Tanzilli

  3. Department of Human and Social Sciences, University of Bergamo, Bergamo, Italy

    Attà Negri

Corresponding author

Correspondence to Christopher Christian.

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Christian, C., Bincoletto, A.F., Mariani, R. et al. Specificities of Mental Functioning and Referential Process in Body Dysmorphic Disorder: A Single Case Study Using the Psychodynamic Diagnostic Manual (PDM-2). J Psycholinguist Res 54, 46 (2025). https://doi.org/10.1007/s10936-025-10162-4

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  • DOI https://doi.org/10.1007/s10936-025-10162-4

Keywords

  • PDC-2
  • PDM-2
  • Body dysmorphic disorder
  • Referential process
  • Assessment
  • Psychodynamic treatment

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