Case Study
Patient Demographic: Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs
Mental Status Exam: Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety
Presenting Problem: You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI).
Other Contexts: The client has been free of suicidal ideation for four weeks now. Psychoeducation has helped him gain insight into BDD. Distance counseling has been effective in decreasing ritualistic behaviors, and you provide face-to-face sessions every other week to help decrease avoidance behaviors. The client has benefited from cognitive-behavioral therapy (CBT). He attended two social events this month and has decreased ritualistic “safety behaviors” once used to prevent a feared consequence. He would like to take two college courses in the fall and is nearing the termination stage of therapy

Question: Which one of the following would qualify as the client’s ritualistic safety behaviors?
(A): Wearing a beanie or hoodie while away from home
(B): Agreeing to contact the counselor if he experiences suicidal ideations
(C): Identifying core beliefs that contribute to anxiety in social situations
(D): Complying with his selective serotonin reuptake inhibitor (SSRI) medication

Correct Answer: Wearing a beanie or hoodie while away from home
Explanation: Wearing a beanie or hoodie while away from home is a safety behavior. Safety behaviors are used to prevent, diminish, or escape what is perceived as a feared catastrophe. Like other avoidance behaviors, safety behaviors create a positive feedback loop that reinforces anxiety due to cognitive misattributions of safety. Complying with his SSRI medication is not considered to be a safety behavior. Unlike fast-acting medications such as benzodiazepines, SSRIs do not provide immediate onset. Carrying a fast-acting medication such as a benzodiazepine would qualify as a safety behavior. Agreeing to contact the counselor if he is experiencing suicidal ideation is not classified as a ritualistic safety behavior. Core beliefs, which are generally long held, rigid, and pervasive, contribute to the client’s anxiety rather than ensuring safety. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis