The road to symbolization. PDM-2 and linguistic measures in dialogue for the study of body dysmorphic disorder treatment

Introduction: Body Dysmorphic Disorder (BDD) involves an intense preoccupation with perceived physical flaws, leading to significant emotional distress and impairments in interpersonal relationships. The complexity of BDD, often accompanied by comorbid personality disorders and deficits in mental functioning, makes it a challenging condition to diagnose and treat. The Psychodynamic Diagnostic Manual (PDM-2) and Multiple Code Theory offer a comprehensive framework for assessing and understanding this complexity. This study aimed to discuss a clinical case of a patient suffering from BDD and illustrate the main improvements in personality, mental, and psychopathological functioning, focusing on changes in the process of symbolization from the early to middle stages of his treatment. Methods: Mr. C was assessed by applying the Psychodynamic Chart-2 (PDC-2) of the PDM-2 and linguistic measures to the verbatim transcripts of three initial and three intermediate therapy sessions. The PDC-2 is a clinician report tool useful for promoting accurate psychodynamic diagnoses and case formulations, as well as monitoring and evaluating treatment outcomes. The linguistic measures included the Weighted Referential Activity Dictionary (WRAD), which captures Referential Activity (RA)—a person’s ability to communicate emotional experiences and evoke corresponding experiences in others—and the Weighted Reflecting and Reorganizing List (WRRL), which evaluates the reorganizing and reflecting linguistic style. They were used to evaluate the extent to which the patient was able to recognize and understand the emotional significance of events. Results: At the early stages of therapy, Mr. C presented with severe BDD, comorbid somatizing and schizoid personality disorders, and significant impairments in mentalization, affective and self-esteem regulation, as well as in capacities for relational intimacy and self-observation. His speech showed a markedly concrete linguistic style, indicating great difficulty in symbolizing. Throughout therapy, there were noticeable improvements in Mr. C's overall psychological functioning. At the intermediate stage of treatment, it was found that Mr. C’s personality organization shifted from borderline to neurotic level; the severity of somatizing, schizoid, anxious-avoidant, and phobic personality disorders shifted from high to moderate. Additionally, the assessment of mental functioning showed improvement in several areas. Finally, Mr. C confirmed enhancement in BDD symptoms. Similarly, the linguistic measures revealed an increase in the patient’s symbolization capacities, indicating slow but significant changes. The therapist’s interventions helped Mr. C articulate his emotional experiences, co-creating a narrative that fostered better mentalization and emotional processing. Conclusions: This single-case study underscores the importance of a nuanced and comprehensive approach to assessing and treating BDD. The use of PDM-2 and Referential Process language measures also provided valuable insights into the therapeutic process. The tailored therapeutic interventions facilitated a gradual improvement in Mr. C’s symptomatology, reflecting relevant changes in his personality and mental functioning, as well as in his capacity in articulating and process deep-seated emotional experiences. Findings underline the importance of promoting a multidimensional approach that allows a functional understanding of patient changes in the treatment process.