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: You and the client review his safety plan. The client believes the antidepressant has helped decrease his feelings of hopelessness and suicidality. Despite the hot and humid conditions, the client arrives at his counseling session in a hoodie. He explains that he has been getting out of the house “some” but continues to avoid social situations because of overwhelming thoughts of others staring at him and mocking his appearance. The client was a no-show for his appointment last week and has requested distance counseling to avoid anxiety experienced when leaving the house. You and the client work together to set appropriate treatment plan goals; however, this is difficult due to poor insight into his presenting problem. You provide psychoeducation about BDD and ask about his goals for the future.  The client does not believe psychotherapy is the best solution to his problems

Question: The client does not believe psychotherapy is the best solution to his problems. How should you respond to his lack of insight and motivation to change?
(A): “When I look at you, I don’t see the imperfections you point out.”
(B): “I’m wondering if you can keep a journal to record your thoughts and feelings when looking in the mirror”
(C): “How does preoccupation with your appearance stop you from participating in life?”
(D): “Can we examine how your distress is rooted in the core beliefs you developed as a child?”

Correct Answer: “How does preoccupation with your appearance stop you from participating in life?”
Explanation: The best response is: “How does preoccupation with your appearance stop you from participating in life?” Individuals with BDD often exhibit poor insight due to delusional beliefs about their appearance and delusions of reference. Experts suggest psychoeducation, coupled with empathy and a non-judgmental stance, can help improve insight and increase motivation to change. Experts advise against arguing or disagreeing with inaccurate perceptions, which makes answer A incorrect. Core beliefs and individual schemas can contribute to inaccurate perceptions, particularly when the perceptions are tied to poor self-worth; however, answer C is incorrect because an individual must first develop insight and motivation prior to tying cognitive distortions to core beliefs from childhood. Recording thoughts and feelings is helpful for examining cognitive distortions; however, this response is less likely to help improve insight and increase motivation to change. Therefore, the correct answer is (B)
Competency: counseling skills and interventions