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:     plan. Family History: The client’s parents are divorced and he lives with his mother and two younger siblings. There is a history of child protective services (CPS) involvement due to reports of domestic violence between his parents. The client witnessed these incidents between that ages of 10 and 12. His parents subsequently divorced and the client has had minimal contact with this father since. The client’s maternal aunt is diagnosed with obsessive-compulsive disorder. His mother previously attended therapy for anxiety and other trauma-related symptoms. The client began experiencing symptoms of body dysmorphic disorder at age 13, with symptoms worsening after starting high school.  With the overall goal of creating anxiety habituation, you instruct the client to gradually face feared social situations without performing ritualized tasks (e\. g., mirror-checking)

Question: With the overall goal of creating anxiety habituation, you instruct the client to gradually face feared social situations without performing ritualized tasks (e.g., mirror-checking). This is an example of which of the following?
(A): Behavior activation
(B): Distress tolerance
(C): Exposure and response prevention
(D): Cognitive diffusion

Correct Answer: Exposure and response prevention
Explanation: Instructing the client to gradually face feared social situations without performing ritualized tasks (eg, mirror-checking) is known as exposure and response prevention (ERP). Exposure and response prevention, also known as ritual prevention, is an evidence-based practice for BDD treatment. ERP involves suggesting that the client remain in social situations until the urge to ask for reassurance or engage in mirror-checking decreases noticeably. Anxiety habituation occurs when the desire for the client to engage in mirror-checking discontinues indefinitely. Cognitive defusion, also called deliteralization, is used in acceptance and commitment therapy (ACT). The goal of cognitive defusion is to recognize and detach from thoughts that contribute to increased anxiety. Behavioral activation is a treatment for depression that involves identifying and initiating values-based activities to help lift depression rather than waiting for depression to lift before participating in values-based activities. Distress tolerance is a dialectical behavior therapy (DBT) technique that teaches radical acceptance of the present situation by using coping skills such as self-soothing and distraction. Therefore, the correct answer is (D)
Competency: counseling skills and interventions