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.  During a CBT exercise, you discover that the client believes his “defective” appearance makes him unworthy of love

Question: During a CBT exercise, you discover that the client believes his “defective” appearance makes him unworthy of love. This is an example of which of the following?
(A): Automatic thought
(B): Core belief
(C): Intermediate belief
(D): Hot thought

Correct Answer: Core belief
Explanation: This is an example of a core belief. Core beliefs are generally long-held, rigid, and pervasive beliefs that are often formed in childhood. The client equates his external attributes, which are distorted perceptions, with being unworthy or unloved. Cognitive restructuring is one mode of CBT used to address core beliefs. Intermediate beliefs occur between automatic thoughts and core beliefs. When an automatic thought (ie, an immediate internal reaction) is generated, there is an intermediate process involving conditions and rules. For example, “If my appearance were not defective, I would be successful and worthy” Intermediate thoughts categorize these assumptions and are driven by core beliefs. Automatic thoughts are immediate, knee-jerk reactions to events or situations. Not all automatic thoughts are negative. It is the unhelpful automatic thoughts that counselors must help clients identify when using cognitive restructuring and other CBT techniques. Hot thoughts are automatic thoughts that happen along with an emotional change. Therefore, the correct answer is (C)
Competency: counseling skills and interventions