What is the best course of treatment for a 14-year-old patient with adhenonia, anxiety, and social anxiety disorder, who always wants to hide their face?

Assessment and Treatment for a 14-Year-Old with Anhedonia, Anxiety, and Face-Hiding Behavior

This adolescent requires immediate assessment for Body Dysmorphic Disorder (BDD), as the face-hiding behavior is a classic presentation that is frequently misdiagnosed as social anxiety disorder alone, leading to suboptimal treatment. 1

Critical Diagnostic Consideration

Screen directly for appearance-related concerns, as young people with BDD rarely disclose these spontaneously but will respond if asked directly. 1 The combination of anxiety, anhedonia, and persistent face-hiding behavior strongly suggests BDD rather than isolated social anxiety disorder, particularly given the specific avoidance pattern. 1

Key Assessment Questions to Ask Directly

Ask the following questions to differentiate BDD from social anxiety disorder:

• "Do you spend a lot of time worrying about how your face looks?" 1
• "How much time during the day do you think about your appearance?" 1
• "Do you avoid situations or try to hide your face because you're worried about how it looks?" 1
• "Do you spend time comparing your face to others?" 1

Be vigilant for behavioral clues during assessment: wearing hoods, hats, or keeping the camera off during video sessions are red flags for BDD. 1

Treatment Algorithm

If BDD is Confirmed (Most Likely Scenario)

Start with specialized CBT for BDD combined with an SSRI (sertraline preferred for adolescents). 2, 3 The CBT must be BDD-specific, not generic anxiety treatment, as standard social anxiety protocols will be insufficient. 1

BDD-specific CBT components include: 1

• Exposure and Response Prevention (ERP): Confronting social situations while resisting urges to hide the face or engage in checking behaviors 1
• Behavioral experiments to test beliefs about appearance-related judgments 1
• Mirror retraining to process appearance as a whole rather than fixating on perceived flaws 1
• Eliminating safety behaviors like covering the face, excessive grooming, or reassurance-seeking 1

Pharmacotherapy: 2, 3

• Start sertraline 25-50 mg daily, titrating slowly based on response 2
• SSRIs are first-line for both BDD and comorbid anxiety 3
• Expect 10-12 weeks for full therapeutic response 3

If Social Anxiety Disorder Without BDD

Begin with individual CBT specifically designed for social anxiety disorder, focusing on exposure therapy and cognitive restructuring. 2 Individual sessions are superior to group therapy for adolescents. 2

Add an SSRI if CBT alone is insufficient or symptoms are severe: 2

• Sertraline or escitalopram are preferred due to favorable safety profiles 2, 3
• Start at lower doses than adults and titrate slowly 2

Addressing Anhedonia

The anhedonia component requires specific attention, as traditional SSRIs may have limited benefit or even worsen anhedonia in some patients. 4 Consider:

• Behavioral activation as part of CBT to address social withdrawal and low motivation 4
• If anhedonia persists despite SSRI treatment, consider switching to vortioxetine or agomelatine, which show superior efficacy for anhedonia 4
• Anhedonia is an independent risk factor for suicidality and requires careful monitoring 4

Critical Assessment Components

Conduct comprehensive suicide risk assessment, as adolescents with anxiety disorders have 24% prevalence of suicidal ideation and 6% attempt rate. 1 The combination of anxiety, anhedonia, and potential BDD significantly elevates this risk. 1, 4

Assess for comorbid depression, as generalized anxiety with comorbid depression conveys the greatest suicide risk. 1 The presence of anhedonia suggests possible depressive features requiring additional intervention. 4

Involve parents in assessment but interview the adolescent separately about appearance concerns, as parents may be engaging in "family accommodation" behaviors that perpetuate BDD. 1 Parents often provide excessive reassurance or facilitate avoidance, unintentionally fueling the disorder. 1

Common Pitfalls to Avoid

Do not provide reassurance about the adolescent's appearance or attempt to challenge their beliefs during initial assessment—this will be perceived as dismissive and damage therapeutic rapport. 1

Do not misdiagnose BDD as social anxiety disorder alone, which occurs frequently and leads to suboptimal treatment. 1 While these conditions can coexist, the face-hiding behavior suggests appearance-related preoccupation requiring BDD-specific intervention. 1

Avoid benzodiazepines for routine treatment due to addiction potential in adolescents. 3

Do not use paroxetine or fluoxetine as first-line options due to higher adverse effect rates. 3

Monitoring and Duration

Continue treatment for at least 4-12 months after symptom remission for a first episode. 2

Use validated outcome measures at every session to monitor progress: 3

• Liebowitz Social Anxiety Scale (LSAS) or Social Phobia Inventory (SPIN) for social anxiety 3
• Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS) if BDD is present 3

Monitor medication response carefully, as adolescents may respond differently than adults to psychotropic medications. 2