The Optical-Coenaesthetic Disproportion Hypothesis of Feeding and Eating Disorders in the Light of Neuroscience

Psychotic-like anomalous self-experiences in feeding and eating disorders: Their role in eating psychopathology through the mediation of body uneasiness and embodiment and identity disorders

BACKGROUND

Psychotic-like anomalous self-experiences (ASEs) are core and early features of schizophrenia spectrum disorders, which have been recently also postulated to underlie embodiment disturbance in feeding and eating disorders (FEDs). The present study was aimed at investigating the interplay between ASEs and specific psychopathology in FED.

METHODS

Ninety persons with Anorexia Nervosa and 41 with Bulimia Nervosa were evaluated with the inventory of psychotic-like anomalous self-experiences (IPASE), identity and eating disorders (IDEA), body uneasiness test (BUT), and eating disorder examination questionnaire (EDE-Q). The same assessment was performed for 92 subjects recruited from the general population. Structural equation modelling was employed to test the role of embodiment/identity disorders in mediating the relationship between ASEs and ED psychopathology.

RESULTS

Patients with FED displayed high scores on IPASE, comparable with people with schizophrenia spectrum disorders. A significant correlation was also demonstrated between IPASE, BUT and EDE-Q. All IPASE domains were strongly related to feeling extraneous from one's own body by IDEA. All IPASE domains demonstrated a high relationship with BUT Depersonalization scale. A strong correlation was also reported between total scores of IPASE and IDEA. The mediation model confirmed that ASEs impact on FED symptomatology through the mediation of both embodiment/identity disorders and body image.

DISCUSSION

Anomalous interoceptive processes may represent the first step of a maladaptive process-impairing embodiment, selfhood, and identity in FED. Assessment of ASEs might be a valid tool to identify an early-shared vulnerability of severe disorders characterized by embodiment alterations.

Autobiographical Memory in Feeding and Eating Disorders: A Systematic Review

INTRODUCTION

Prominent eating disorders (EDs) theories identify a critical relationship between body and self. One of the ways to study this relationship is through autobiographical memories (AMs). The present review aimed to evaluate the studies that investigated AM in patients with EDs.

METHODS

A search of PubMed, ScienceDirect, and Scopus databases was performed to identify relevant articles. Of the 57,113 studies found, 25,016 were not duplicated. After screening, 27 articles were included.

RESULTS

The studies had some methodological flaws: none of the articles was a randomized control trial and the sample sizes were small. Nevertheless, important evidence emerged because all studies showed that patients with EDs have impaired AM function. This is because the way patients with EDs remember and define themselves is through an allocentric perspective associated with the gazes of others whose role has an impact on AM, body shape, and self.

CONCLUSION

To our knowledge, this is the first systematic review to examine AM in patients with EDs. Future research is needed in EDs to expand knowledge about the relationship between the body and the self.

Disordered eating in a 10-year perspective from adolescence to young adulthood: Stability, change, and body dissatisfaction as a predictor

INTRODUCTION

Although there are many studies of disordered eating (DE) in adolescence, studies examining the longitudinal stability and change of DE and its longitudinal associations with other factors are still rather scarce. Such studies are important to inform parents and clinicians how stable DE is and to what extent it will go away with increased maturity. Longitudinal studies may also be of help in establishing predictors of long-term problems. The purpose of the present study was to investigate the stability of DE over a 10-year period from early adolescence to young adulthood, and to explore body dissatisfaction as a predictor in a 10-year perspective.

METHODS

Data were taken from a three-wave longitudinal project (SoL) with survey data collected among the students in Grades 7and 8 in a Swedish municipality in 2007 (T1), 1 year later (T2), and in a 10-year follow-up in 2017 (T3). DE was measured by the eight-item version of the Risk Behaviour Related to Eating Disorders (RiBED-8), and a quasi-clinical criterion of six or more critical answers on the RiBED-8 was used to classify DE cases.

RESULTS

Of the girls, 5.8% passed the cutoff for DE at T1, whereas 9.1% did so at T2 and 7.9% at T3. The boys showed markedly lower figures: 0.5% both at T1 and T2, and 1.5% at T3. There was significant individual stability of DE over the 10-year period, with almost 30% of the girls who passed the cutoff for DE at T1 also doing so 10 years later. Body dissatisfaction in early adolescence predicted the incidence of new cases of DE 10 years later, even when controlling for degree of DE in early adolescence. The results also indicate that DE in early adolescence may be a passing phase among adolescents who express relatively high body satisfaction.

CONCLUSIONS

The present results show a complex picture of different individual trajectories of DE, with degree of body satisfaction playing a significant role for the outcome in a 10-year perspective. Body dissatisfaction appears to be a risk factor for the development of new cases of DE, whereas body satisfaction may protect against the continuation of DE into adulthood.

The primacy of ocular perception: a narrative review on the role of gender identity in eating disorders

BACKGROUND

Phenomenological research has enriched the scientific and clinical understanding of Eating Disorders (ED), describing the significant role played by disorders of embodiment in shaping the lived experience of patients with ED. According to the phenomenological perspective, disorders of embodiment in ED are associated with feelings of alienation from one's own body, determining an excessive concern for external appearance as a form of dysfunctional coping. The purpose of the present narrative review is to address the role of gender identity as a risk factor for EDs in the light of phenomenological approaches.

METHODS

Narrative review.

RESULTS

The current study discusses the interplay between perception, gender identity, and embodiment, all posited to influence eating psychopathology. Internalized concerns for body appearance are described as potentially associated with self-objectification. Furthermore, concerns on body appearance are discussed in relation to gendered social expectations. The current review also explores how societal norms and gender stereotypes can contribute to dysfunctional self-identification with external appearances, particularly through an excessive focus on the optical dimension. The socio-cultural perspective on gender identity was considered as a further explanation of the lived experience of individuals with ED.

CONCLUSIONS

By acknowledging the interplay between these factors, clinicians and researchers can gain a deeper understanding of these disorders and develop more effective interventions for affected individuals.

LEVEL OF EVIDENCE

Level V narrative review.

The impact of floatation therapy on body image and anxiety in anorexia nervosa: a randomised clinical efficacy trial

Background

Body image disturbance and anxiety are core features of anorexia nervosa (AN), a psychiatric disorder with one of the highest mortality rates. This study examined the efficacy of a novel non-pharmacological treatment, floatation-REST (Reduced Environmental Stimulation Therapy) on body image disturbance and anxiety in inpatients with AN.

Methods

This parallel group randomised controlled trial compared floatation-REST vs. care as usual in women and girls hospitalised for treatment of AN in Tulsa, Oklahoma, USA. Participants were randomised on a 2:1 ratio to receive eight, twice-weekly, 60-min floatation-REST sessions for 4 weeks, in addition to care as usual, or to receive care as usual. The primary outcome was the average change in body dissatisfaction from pre- to post-float as measured by the Photographic Figure Rating Scale. The secondary outcome was the average change in anxiety from pre- to post-float as measured by the state version of the State Trait Anxiety Inventory. Longitudinal effects of floatation-REST on body dissatisfaction were also examined. All analyses were conducted using the intention-to-treat principle. Planned linear mixed models tested the effect of floatation-REST vs. care as usual. The trial was preregistered (clinicaltrials.govNCT03610451).

Findings

Between March 16, 2018 and February 25, 2021, 133 participants were screened for eligibility, and 86 were consented. Eighteen were excluded after consent, for a final randomisation sample of 68 participants (45 floatation-REST; 23 care as usual). There were two session by condition interactions on body dissatisfaction (p = 0.00026) and state anxiety (p < 0.0001), such that the floatation-REST group exhibited acute (i.e., pre- to post-session) reductions in body dissatisfaction (floatation-REST group mean change (Δm) = -0.43; 95% CI -0.56 to -0.30, p < 0.0001, Cohen's d = 0.23), and acute reductions in anxiety (floatation-REST group Δm = -15.75; 95% CI -17.95 to -13.56, p < 0.0001, Cohen's d = 1.52); however, the care as usual group exhibited no significant changes. With regard to longitudinal results, there was a significant time by treatment interaction between baseline and immediately post intervention (p = 0.012) and baseline and six-month follow up (p = 0.0019). At immediately post intervention, there was a trending reduction in body dissatisfaction for the floatation-REST group (Δm = -0.41, 95% CI -0.86 to 0.03, p = 0.068) and care as usual group (Δm = 0.61; 95% CI -0.04 to 1.27, p = 0.070). At six-months post-intervention, the floatation-REST group exhibited lower body dissatisfaction (Δm = -0.91; 95% CI -1.37 to -0.45, p = 0.0020, Cohen's d = 0.53) whereas the care as usual group reported no change in body dissatisfaction (Δm = 0.35; 95% CI -0.28 to 0.98, p = 0.96) relative to baseline. There were no adverse events related to the trial during the study.

Interpretation

Our findings suggest that Floatation-REST decreased body dissatisfaction compared to care as usual acutely after each float session and at six-month follow-up. Floatation-REST has potential utility for the treatment of body image disturbance and anxiety in AN. These results may be limited by some generalisability concerns given the recruitment of a modest sample receiving inpatient treatment at a single site.

Funding

The William K. Warren Foundation.

Pregorexia: a systematic review and meta-analysis on the constructs of body image dissatisfaction and eating disturbances by gestational age in the peripartum

PURPOSE

Pregorexia is a phenomenon posited to occur in the peripartum, characterized by an attempt to counter pregnancy's physiological changes in body shape through reduced calorie intake or increased physical activity.

METHODS

In this pre-registered systematic review and meta-analysis, body image dissatisfaction and eating psychopathology in the peripartum according to gestational age were formally assessed. PubMed was searched up to May 2023. Selection criteria were represented by studies on body image concerns or eating psychopathology in the peripartum (up to 1 year after delivery). The population needed to include women from the general population or among patients with a history of (or current) eating disorder. For the meta-analysis, 17 studies were included: 10 for body image dissatisfaction (2625 individuals overall), 7 for eating behaviors (2551 individuals overall). The interplay between body image and the following themes was examined in depth: the adoption of breastfeeding, peripartum depression, sociocultural influences on body image, sexual disturbances, experiencing or reporting an altered food intake.

RESULTS

Progressive dissatisfaction with body image during pregnancy by gestational age was observed, stably elevated for at least 12 months postpartum. Eating psychopathology was observed as elevated only at 12 months in the postpartum, but not during pregnancy.

DISCUSSION

The current work offers normative values of body image satisfaction and eating psychopathology in the peripartum by gestational age. The relevance of current results was discussed, in order to inform both current clinical practice and future public policies.

LEVEL OF EVIDENCE

Level I-Evidence obtained from: systematic reviews and meta-analyses.

Anorexia nervosa as a disorder of the subcortical-cortical interoceptive-self

PURPOSE

Anorexia nervosa (AN) is characterized by a diminished capacity in perceiving the physiological correlates of interoceptive sensations, namely bodily self-consciousness. Given the neural division of self-processing into interoceptive-, exteroceptive- and mental-self, we hypothesize neural deficits in the interoceptive-processing regions in AN.

METHODS

To prove this, we reviewed resting state (rs), task and rest-task studies in AN literature.

RESULTS

Neuronal data demonstrate the following in AN: (i) decreased rs-functional connectivity (rsFC) of subcortical-cortical midline structures (SCMS); (ii) reduced rsFC between medial (default-mode network/DMN and salience network/SN) and lateral (executive-control network/ECN) cortical regions; (iii) decreased rsFC in mainly the regions of the interoceptive-self; (iv) altered activity with overall increased activity in response to sensory/body image stimuli, especially in the regions of the interoceptive-self; (v) lack of a clear task-related distinction between own's and others' body image.

CONCLUSION

These data may indicate that rs-hypoconnectivity between SCMS, as neural correlate of a reduced intero-exteroceptive integration resulting in self-objectification, might be linked to overall increased activity in interoceptive regions during sensory/body image stimuli in AN, engendering an "anxious bodily self."

LEVEL OF EVIDENCE

I: Systematic review.

Associations Between Eating Attitudes, Mental Health, and Sexual Dysfunction during Pregnancy

This cross-sectional study looked into sexual dysfunctions in a sample of Lebanese pregnant women (N = 433) while assessing their psychopathological correlates. It was a first attempt in research to examine the role of disordered eating attitudes in pregnancy, using the Arabic version of the Disordered Eating Attitudes in Pregnancy Scale. The pre/post comparison in terms of sexual functioning was based on the women's recall, using the Pregnancy Sexual Response Inventory. According to the pregnant persons perceptions of their sexual functioning before and during pregnancy, 66.1% of the participants reported a lower frequency of sexual activity during pregnancy, 52.7% lower sexual desire, and 47.3% dyspareunia; 33% were sexually satisfied contrasted to 70% before pregnancy. Pregnancy was significantly associated with lower sexual outcomes compared to before. Higher anxiety and more disordered eating attitudes during pregnancy were significantly associated with lower sexuality composite scores. Our study accentuates the need for rigorous medical guidance on sexual activity during pregnancy and highlights dysfunctional eating behaviors and anxiety disorders as pejorative predictors of the sexual response among pregnant women. It thus sustains the hypothesis that mental health disorders pertain to the pathogenesis of sexual problems and should therefore be targeted in sexual health promotion during prenatal care.

Bridging cognitive, phenomenological and psychodynamic approaches to eating disorders

Cognitive, psychodynamic, and phenomenological scholars converged their attention on abnormal bodily phenomena as the core psychopathological feature of eating disorders (EDs). While cognitive approaches focus their attention on a need for "objective" (i.e., observable, measurable) variables (including behaviours and distorted cognitions), the phenomenological exploration typically targets descriptions of persons' lived experience. According to a new emerging phenomenological perspective, the classic behavioural and cognitive symptoms of EDs should be considered as epiphenomena of a deeper core represented by a disorder of the embodiment. The cognitive-behavioural model is the most studied and, up till now, clinically efficacious treatment for EDs. However, as any coherent and scientifically grounded model, it presents some limitations in its application. Numerous patients report a chronic course, do not respond to treatment and develop a personality structure based on pathological eating behaviours, since "being anorexic" becomes a new identity for the person. Furthermore, the etiopathogenetic trajectory of EDs influences the treatment response: for example, patients reporting childhood abuse or maltreatment respond differently to cognitive-behavioural therapy. To obtain a deeper comprehension of these disorders, it seems important to shift attention from abnormal eating behaviours to more complex and subtle psycho(patho)logical features, especially experiential ones. This characterisation represents the unavoidable premise for the identification of new therapeutic targets and consequently for an improvement of the outcome of these severe disorders. Thus, the present review aims to provide an integrated view of cognitive, psychodynamic, and phenomenological perspectives on EDs, suggesting new therapeutic targets and intervention strategies based on this integrated model. Level of Evidence: Level V.Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Se-duction is not sex-duction: Desexualizing and de-feminizing hysteria

The psychopathological analysis of hysteria is a victim of narrow conceptualizations. Among these is the inscription of hysteria in the feminine sphere, about body and sexuality, which incentivized conceptual reductionism. Hysteria has been mainly considered a gendered pathology, almost exclusively female, and it has been associated with cultural and/or religious features over time rather than treated as a psychopathological world. Further, hysteria has been dominated by conceptual inaccuracies and indecision, not only in terms of clinical features but also in terms of its definition. For this reason, it seems necessary to "undress" hysteria from this feminization, sexualization, and corporealization with which it has been abundantly clothed over the years. "Undressing" hysteria will make possible a reconfiguring and deconstructing of the explanatory-causal model of Charcot and Freud. However, if we take out this cultural heritage, the stigma accompanying this diagnosis, and the weight of the enormous historical tradition that hysteria carries, the world of hysteria continues to constitute a domain full of complexity and nosographic challenges. Hysteria has been considered a sum of psychological behaviors and states illustrated by drama, mystery, or falsity. The difficulty in understanding the multiple somatic manifestations which characterize this clinical condition created several controversies and much confusion. In the current nosography, the personological component of hysteria has been separated from its symptomatic manifestation, in the Histrionic Personality Disorder and Conversion Disorder categories, respectively. This segmentation by descriptive nosography does contribute to a unitary understanding of the phenomenon and, consequently, of daily clinical practice. Clinical complexity can be grasped and deciphered only if the symptom is inscribed in the patient's lifeworld and his/her subjective life history. Clinical practice is thus thought of in terms of a structural aggregation of a homogeneous set of phenomena, together constituting a specific way of being in the world. The starting point of this article is the evident modalities characterizing this life-world, taking care not to confuse the point of origin with the point of expression.

The disappearing body: anorexia as a conflict of embodiment

Anorexia nervosa is often regarded primarily as a disorder of the body image, with affected individuals submitting themselves to the dictate of a predominant model of slenderness. However, even though this frequently functions as a gateway to the disorder, the paper intends to show that the actual conflict in anorexia consists in a fundamental alienation of the self from the body. In order to analyze this alienation from a phenomenological point of view, the paper introduces the polarity of lived body (body-as-subject) and physical body (body-as-object). It then explores the phenomenology of anorexia, drawing on characteristic self-reports as well as on the phenomenological, psychoanalytic and cultural science literature. The anorexic conflict of embodiment arises in adolescence, where the body becomes an object of the other's gaze in a special way. Starting with an attempt to comply with the ideal body image, the anorexic patient increasingly fights against her dependency on her body and its uncontrollable nature, above all its hunger and femininity. To be in total control of her body and to gain independence from it, becomes the source of a narcissistic triumph. Thus, in striving for autonomy and perfection, the anorexic patient alienates herself from her embodiment. This results in a radical dualism of 'mind' and 'body': pursuing the ideal of an asexual, angelic, even disappearing body. Anorexia is thus conceived as a fundamental conflict of embodiment.

The role of embodiment in the treatment of patients with anorexia and bulimia nervosa: a 2-year follow-up study proposing an integration between enhanced cognitive behavioural therapy and a phenomenological model of eating disorders

PURPOSE

Recent studies demonstrated that the embodiment disorder represents a core feature of eating disorders (EDs). The aim of this study was to evaluate the role of its variation as a possible mediator of the efficacy of enhanced cognitive behavioural therapy (CBT-E) on classic ED symptomatology, including body uneasiness.

METHODS

73 patients with anorexia nervosa and 68 with bulimia nervosa were treated with a multidisciplinary approach including CBT-E. Psychometric questionnaires were administered at baseline (T0) and after one (T1) and 2 years (T2) to evaluate general and ED-specific psychopathology, body uneasiness and the embodiment disorder. Data regarding diagnostic crossover and remission were also collected.

RESULTS

Longitudinal analysis showed an improvement of all psychopathological dimensions at T1, which remained stable at T2 (p < 0.05). Remission rate at T2 was 44.7%, and diagnostic crossover occurred in 17.0% of patients. Higher levels of embodiment disorder predicted increased diagnostic instability (OR: 1.80 [1.01-3.20], p = 0.045). The amelioration of the embodiment disorder mediated the decrease in both ED-specific psychopathology (indirect effect: 0.67 [0.46-0.92]) and body uneasiness (indirect effect: 0.43 [0.28-0.59]).

CONCLUSION

For the first time, these findings highlighted the role of the embodiment disorder as a maintaining factor of ED symptomatology, supporting the importance of integrating CBT-E with a phenomenological model of EDs.

LEVEL OF EVIDENCE

Level IV, longitudinal observational study (case series).

Lived body and the Other's gaze: a phenomenological perspective on feeding and eating disorders

According to the phenomenological perspective, the lived body disorder is a core feature of feeding and eating disorders (FEDs). Persons with FEDs experience their own body first of all as an object looked by another person, rather than coenaesthetically or from a first-person perspective. In particular, the main features of this disorder are: alienation from the own body and from the own emotions, disgust for it, shame, and an exaggerated preoccupation for the way in which one appears to the others. Phenomenological research has recently highlighted that the gaze of the Other plays an important role. Because persons with FEDs cannot have an experience of their own body from within or coenesthetically, they need to apprehend their own body from outside through the gaze of the Other. This way of apprehending one's own body when it is looked by another person is called by Sartre the 'lived body-for-others'. Normally, the constitution of one's own body, and consequently of one's own Self and identity depends on the dialectic integration between the first-person apprehension of one's body (lived body) that it is based on coenaesthesia, and the third-person one, that it is based on the sense of sight (lived-body-for-others). When the dialectic is unbalanced toward the pole of the lived-body-for-others, experienced from without, the symptom occurs. Starting from these clinical observations, the so-called Optical-Coenaesthetic Disproportion model has been developed. In this paper, we describe this model, its philosophical and clinical foundations, and finally its clinical implication and its relationship with other disciplines, i.e., neurosciences. Level of evidence: V.

Dear Body… An Explorative Study on Anomalous Bodily Experiences in Persons with Feeding and Eating Disorders

OBJECTIVE

The aim of the study was to provide a qualitative analysis of anomalous bodily experiences (ABEs) of persons affected by feeding and eating disorders (FEDs). In particular, this study aimed to refine the description of bodily experiences in persons with FEDs so as to improve their treatment.

SAMPLING AND METHODS

This is a naturalistic explorative study on a group of 29 patients affected by FED in psychotherapeutic treatment and 12 healthy controls. We asked the participants to write a letter on the way they experience their body. Later, we analysed their letters by means of consensual qualitative research.

RESULTS

All patients (29) reported at least 1 ABE. The main categories identified are (1) body-obstacle (the body interposes between the person and the world); (2) body-tyrant (the body imposes itself on the will of the person); (3) body-hyper-visible (the body is experienced as an exposed object); (4) body-geometric (the body is experienced or associated with a geometric form); and (5) body-numerical (the body is defined by numbers). All these categories are present in the clinical group, and they are absent in the control group.

CONCLUSION

To grasp the experiential nuances of ABEs is relevant to understand the disorder of embodied self-hood and personal identity in these patients and thus to refine clinical treatment.

The relationship between eating disorder psychopathology and sexuality: etiological factors and implications for treatment

PURPOSE OF REVIEW

There is a remarkable overlap between eating disorders and sexual problems, both in terms of sexual dysfunctions and risky sexual behaviors. This systematic review of the recent literature aimed at clarifying the nature of this relationship in terms of psychopathological meaning.

RECENT FINDINGS

Body image disturbance, and particularly body dissatisfaction and embodiment disorder, emerged as shared psychopathological dimensions between eating disorder symptoms and sexual dysfunctions. Interpersonal difficulties, a disturbed intimacy and insecure attachment style, but not a history of sexual abuse per se, resulted to play a pivotal role in the interconnection between eating disorder psychopathology and sexual dysfunctions. On the other hand, several studies confirmed the association between eating disorder symptoms and risky sexual behaviors, which has been explained in terms of several common psychopathological dimensions, including impulsivity and addiction.

SUMMARY

Sexuality is deeply interconnected with eating disorder psychopathology, and it should be considered a fundamental aspect in managing these disorders. An accurate assessment of sexual function might allow to characterize etiological information (e.g., sexual abuse) and maintaining factors (embodiment disorder and emotion dysregulation). Accordingly, the recovery of a good sexuality should be considered a crucial signal of recovery.

The Pathogenic and Therapeutic Potential of the Gaze of the Other in the Clinic of "Eating Disorders"

Building on the optical-coenaesthetic disproportion model of so-called eating disorders, this paper provides a framework for the psychotherapy of people affected by these conditions. This model characterizes "eating disorders" as disorders of embodiment and identity, where a sense of unfamiliarity with one's own flesh, experienced as shifting and incomprehensible, leads to an impairment in the constitution of the Self and thus of one's own identity. Since there is a deficit of the coenaesthetic experience of the embodied Self, greater importance is assumed by body perception conveyed from without. To these persons, their corporeality is principally given as a body-object "to be seen" from a third-person perspective, rather than as a body-subject "to be felt" from a first-person perspective. The Other's look serves as an optical prosthesis to cope with dis-coenaesthesia and as a device through which these persons can define themselves. They are unable to accept the hiatus between "being a body" and "having a body," constitutively present in every human being, forcibly trying to recouple it, and finally ending up objectifying themselves to succeed. The external foundation of the Self thus takes the form of a constriction one can never be completely free of. Psychotherapy should thus accompany persons affected by eating disorders in their encounter with the miscarried dialectic between feeling oneself from within and seeing oneself from without through the gaze of the Other, so keenly feared by people desperately in search of self-control. Tactfully, the clinician accompanies the patient in taking a stance towards her symptom as the outcome of this miscarried dialectics, which is one premise for overcoming it. The clinician's gaze becomes the herald of recognition, allowing the patient to feel accepted in terms of her individuality. Feeling themselves touched by a gaze that waives its alienating potential in order to signify acceptance reactivates the identity-forming dialectics. Their body is thus revealed as the receiver of gazes, but also rediscovers its own possibility for self-determination starting out from these gazes. This intersubjective resonance between the clinician's gaze and the patient reactivates the identity-making dialectics between body-subject and body-object, creating the relational premises for overcoming the symptom.