Gerd Overbeck

Separating two components of body image in anorexia nervosa using fMRI

BACKGROUND Body image distortion is a key symptom of anorexia nervosa. In behavioral research two components of body image have been defined: attitudes towards the body and body size experience. Neuroimaging studies concerning own body image distortions in anorexia nervosa have revealed an inconsistent pattern of results and are constrained by the fact that no direct distinction between the different parts of body image has been made. METHOD The present study therefore set out to investigate the neural correlates of two parts of the own body image using functional magnetic resonance imaging (fMRI): satisfaction rating and size estimation for distorted own body photographs in patients with anorexia nervosa and controls. RESULTS Anorectic patients were less satisfied with their current body shape than controls. Patients further demonstrated stronger activation of the insula and lateral prefrontal cortex during the satisfaction rating of thin self-images. This indicates a stronger emotional involvement when patients are presented with distorted images close to their own ideal body size. Patients also overestimated their own body size. We were able to show complex differential modulations in activation of the precuneus during body size estimation in control and anorectic subjects. It could be speculated that a deficit in the retrieval of a multimodal coded body schema in precuneus/posterior parietal cortex is related to body size overestimation. CONCLUSIONS We were able to find specific behavioral responses and neural activation patterns for two parts of body image in anorexia nervosa and healthy controls. Thus, the present results underline the importance of developing research and therapeutic strategies that target the two different aspects of body image separately.

Pain response in depersonalization: A functional imaging study using hypnosis in healthy subjects

Background: Depersonalization (DP) is characterized by persistent or recurrent episodes of detachment from one’s self with reduced pain perception being a common feature. Alterations in the body schema similar to the cortico-limbic disconnection syndrome of pain asymbolia are suggested to be responsible for DP. In this study we used hypnosis to induce DP in healthy subjects and to examine neural patterns of pain perception in the state of DP by means of functional magnetic resonance imaging (fMRI). Methods: Pain perception was investigated in 7 healthy subjects with high susceptibility to hypnosis in three different mental states: waking state (N-W), hypnotic relaxation (H-R) and hypnotic DP (H-DP). Pain was induced with electrical stimulation to the median nerve at the right wrist. fMRI measurements were performed during all states. Results: Nociceptive stimuli led to an activation of the well described pain network including somatosensory and insular regions and the cerebellum. Activation was markedly reduced in the contralateral somatosensory cortex, parietal cortex (Brodmann area 40, BA40), prefrontal cortex (BA9), putamen and the ipsilateral amygdala during H-DP. Subjects also reported a significant decrease in pain intensity from N-W to H-DP. Conclusion: Pain response during H-DP was reduced in sensory and affective pain-related areas, reflecting the diminished intensity of the perceived pain. Moreover, a network of cortical and subcortical areas that have been implicated in the perception of the own body was less responsive during DP, which might point to a specific neural mechanism underlying the ‘out-of-body’ experience. Although the small number of subjects does not allow a generalization of our findings, H-DP seems to be a promising tool for the investigation of psychological and biological mechanisms of self-inflicted injuries as well as the mind-body interplay within the realm of psychosomatic disorders.

The importance of reflective functioning to the diagnosis of psychic structure

OBJECTIVE This pilot study examines the connection between the concept of Fonagy and Targets reflective functioning and the structure axis of operationalized psychodynamic diagnostics (OPD) and assesses the potential of both scales to predict therapy success. METHOD In the study, 24 (female) patients of the psychotherapy ward of the Frankfurt University Hospital for psychosomatic medicine and psychotherapy aged 18 to 55 were assessed on the basis of a 90-minute, semi-structured interview with regard to their capability for reflective functioning as well as with regard to their structural level according to OPD. In addition, the SCL-90-R was administered at the beginning and end of the 3-month in-patient therapy. RESULTS A significant correlation was found between reflective functioning and the structure axis of OPD. Reflective functioning also predicted improvement in overall mental condition through a 3-month in-patient therapy. This remained significant even when the influence of the overall assessment of structure according to OPD was removed. CONCLUSIONS The independence of the concept of reflective functioning (RF) and its implications for the clinical stance are discussed.

Narcissistic Regulation of the Self and Interpersonal Problems in Depersonalized Patients

Background: Psychoanalytical theories coincide in understanding depersonalization (DP) as a disorder of narcissistic self-regulation. DP is described as an ego defense against overwhelming shame resulting in a splitting of an observing ego detached from the experiencing self. In contrast to a behavioral-cognitive theory on DP, which suggests that the catastrophic appraisal of normal transient DP maintains the disorder, psychodynamic approaches stress that DP is an important defensive function for the individual. We examine this psychodynamic aspect more closely as it relates to narcissistic self-regulation and interpersonal behavior in depersonalized patients. Sampling and Methods: Thirty-five patients with pathological DP are compared with 28 patient controls concerning their narcissistic self-regulation and interpersonal behavior. For the assessment, we used the German Narcissism Inventory and the Inventory of Interpersonal Problems. The two groups were controlled for sociodemographic data, comorbidity with a personality disorder, and the General Severity Index of the Symptom Check List-90-R. Results: Bonferroni-corrected group comparison showed that the depersonalized patients are characterized by perceiving themselves as helpless, hopeless, socially isolated and worthless, perceiving others as bad and disappointing, and that they avoid interpersonal relations and reality significantly more than other patients with equal symptom severity. Conclusions: Treatment approaches on DP should take the issue of low self-esteem, pervasive shame and the related defensive social avoidance into account. Further empirical research on psychodynamic concepts of DP is warranted also for the sake of linking modern neurobiological findings with clinical experience.

Depersonalization and social anxiety

Although the literature on depersonalization (DP) indicates links between DP and anxiety disorders, there has been no systematic investigation of the association of DP with social anxiety. The present study explores a hypothesized connection between DP and social anxiety by using correlative and regression analyses in a sample of 116 psychotherapy inpatients, 54 outpatients with epilepsy, and 31 nonpatients. Corresponding to our hypothesis, we found a connection of medium to large effect size between DP and social fears exceeding the impact of general psychopathologic symptom severity both for the psychotherapy patients and the nonpatients. The association of social anxiety with DP merits further research. A general consideration of DP in clinical and neurobiological trials on anxiety disorders like social phobia is warranted.

The therapeutic relationship as reflected in linguistic interaction: Work on resistance

Abstract Although resistance is a concept that, since Freud, has been regarded as central to the course of the therapeutic relationship, it has been the focus of relatively little empirical research. In this case study, the authors attempt to bring to light the resistance in the course of a psychoanalytically oriented short-term therapy in formal-linguistic terms as well as in the interactive behavior between therapist and patient and to examine the connections between them. The interactive behavior is tracked using the Structural Analysis of Social Behavior. Resistance as manifested in speech is analyzed using several Formal Psycholinguistic Text Analysis (Overbeck, Müller, Jordan, & Grabhorn, 1996) items: speech activity, style of conversation, pauses, acknowledgment tokens, interrupting, overlapping, various personal pronouns, and use of passive voice. Various parameters in both methodological approaches provide evidence of a pronounced resistance behavior at the beginning of therapy. Diminished resistance and the establishment of a working alliance characterize the middle phase of therapy. In the last therapy segment, there are signs of beginning autonomy development. Because of the convergence of the measurements, the results of this study can largely be considered reliable.

Drei stationäre Therapieverläufe von essgestörten Patientinnen, verglichen mit der Methode des Zentralen Beziehungskonfliktthemas (ZBKT)

In this article the results of a research with the CCRT-method on the psychotherapies of three in-patients suffering from eating disorders are presented. The CCRT describes recurrent internal and interpersonal relationship patterns in narratives. Each therapy session was recorded on tape and transcribed. The CCRT components were identified from the verbatim transcripts. All three patients clearly showed a negative self-perception and despite a more graded attitude regarding other people they felt rejected by the community throughout the entire therapy. The CCRT of each patient was different: patient 1. had conflicts between dependence and independence with increasing autonomy; patient 2. had great symbiotic desires, which at the beginning of the therapy were warded off with a performance ideal; patient 3. showed self-assertion and an increasing level of openness against the community, despite a high level of fear and self-isolation at the onset of therapy. Despite methodological deficiencies the CCRT method proved to be sensitive enough to show similarities and differences among the individual courses of treatment.

Differentiation in Self- and Object-Perception as a Goal in Psychodynamic Short-Term Therapy: A Cluster-Analytical Evaluation

In this paper, the question is examined as to how object relationship patterns can be adequately recorded and evaluated in the therapy process. Based on the consideration that the differentiation of object perception and its relationship patterns is a goal of psychodynamic therapy, a method for measuring repetitive interaction patterns is presented as an indicator of change. An approach based on cluster analysis offers the opportunity to record and evaluate the entire structure of a therapy without taking individual qualitative features out of their context to one another and to the specific object. The therapy records of a 3-month inpatient psychotherapy were evaluated with a content analysis, using the Structural Analysis of Social Behavior (SASB). The results of the cluster-analytical evaluation of this content analysis provide convincing evidence that the structure of the described object relationships can be recorded, and their transformation processes can be demonstrated with this process in the cou...