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

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.