Case Study
Patient Demographic: Initial Intake: Age: 43 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client presents appropriately dressed in a long-sleeved t-shirt and jeans and is well-groomed. Her weight appears appropriate to height and frame. Her movements and speech demonstrate no retardation and she is cooperative and engaged. The client reports her mood as anxious, however you note her to be relaxed in speech and appearance. She reports no recent suicidal ideations and demonstrates no evidence of hallucinations or delusions. The client reports that she is in good health and takes no medication except birth control.  She reports she has difficulty falling asleep at night because she worries whether her husband finds her attractive. She states she also frequently worries about the children or situations that have happened during the day, but is often able to dismiss these after a few minutes.
Presenting Problem: You are a counselor in a private practice setting.  During the intake session, you learn that your client has been married for 15 years and has four children and is currently struggling with her marital relationship. She states her husband does not want to attend counseling with her. Your client complains of occasional feelings of unhappiness, irritation, difficulty sleeping, as well as worrying. These have been present for the past 8 to 10 months, with the worry being almost daily. She states she feels alone in the marriage because her husband is an introvert and is often too tired after work to engage emotionally with her. She views the marriage as “good” and they engage in sex at least 5 times per week, where she is often the initiator. She reports that she repeatedly asks her husband and best friend to reassure her that she is still attractive. She tells you that her best friend is encouraging, but her husband tells her he is tired of her constant, daily questioning and says she must be in a midlife crisis. She confides that her husband frequently looks at pornography and sometimes they watch pornographic movies together prior to sex.
Other Contexts: Family History:
Approximately 6 years ago, the client’s family doctor prescribed a short course of Valium, while she and her husband were building their house. She also was diagnosed with postpartum depression after her first child was born. She reports she did not seek counseling at the time but her obstetrician prescribed antidepressants, which she took for 10 months with good results. Her doctor then prescribed the same antidepressants for 12 months as a preventative against postpartum depression prior to each of her subsequent births.

Question: In planning treatment goals for this client, which of the following would be the most effective counseling goal for this diagnosis?
(A): Encourage client's husband to attend marital counseling to strengthen relationship
(B): Explore childhood neglect and/or abuse, often related to body dysmorphic disorder
(C): Challenge automatic negative thoughts about body image
(D): Identify a support system that reassures client that she is attractive

Correct Answer: Challenge automatic negative thoughts about body image
Explanation: Cognitive behavioral interventions such as challenging automatic thoughts is the standard treatment for body dysmorphic disorder. Childhood neglect and abuse are often related to body dysmorphic disorder, and exploring these may facilitate client insight, which can be helpful in actual treatment. Effective treatment of this disorder requires the client to reduce reassurance seeking behaviors. Having a support system that provides the reassurance the client constantly is seeking does not help the client reduce her own anxiety about her body image or the need for constant reassurance. Having the client's husband attend therapy to focus on the relationship is not likely to reduce the client's body dysmorphia symptomatology as it is an ingrained pattern. Therefore, the correct answer is (A)
Competency: counseling skills and interventions