What is the most appropriate next step in managing a 16-year-old girl with body dysmorphic disorder (BDD), characterized by a preoccupation with perceived ear deformity, social withdrawal, and depressive symptoms, despite having normally sized ears?

From the Guidelines

The most appropriate next step in management for this 16-year-old girl is to prescribe fluoxetine and recommend cognitive behavioral therapy (option D). This patient is displaying classic symptoms of body dysmorphic disorder (BDD), characterized by her preoccupation with a perceived defect in her physical appearance (her ears) that is not observable to others, significant distress, time-consuming rituals (spending hours fixing her hair), frequent checking behaviors, and functional impairment (quitting activities, avoiding social events) 1. The combination of an SSRI like fluoxetine along with cognitive behavioral therapy represents the first-line treatment for BDD, as recommended by the NICE guidelines 1.

Some key points to consider in the management of BDD include:

• BDD is relatively common in youth, especially among adolescent girls, but often goes undiagnosed or is misdiagnosed 1.
• Young people with BDD tend not to disclose their symptoms unless directly asked 1.
• BDD is associated with high rates of school absenteeism, self-harm, and suicide attempts 1.
• Cosmetic treatments are not recommended for young people with BDD, even if legally available 1.

The CBT for BDD in young people comprises three main stages: psychoeducation and formulation, exposure with response prevention and/or behavioral experiments, and relapse prevention 1. The main focus is on exposure and response prevention (ERP), which involves encouraging the young person to gradually confront feared or avoided situations, while resisting the urge to engage in compulsive, safety behaviors 1.

Fluoxetine would typically be started at a low dose (e.g., 10-20mg daily) and gradually increased as needed, with CBT focusing on exposure and response prevention techniques to address the checking behaviors and cognitive restructuring to challenge distorted beliefs about appearance. Simply reassuring her that her ears look normal would be ineffective as patients with BDD cannot be reassured about their appearance. Discussing cosmetic surgery would be inappropriate as it could reinforce her distorted body image and surgical outcomes are often poor in BDD patients. Mirror exercises might be incorporated later in therapy but aren't the most appropriate initial step. Having the mother describe the daughter's appearance could increase distress and shame without addressing the underlying disorder.

The key components of CBT for BDD are outlined in Table 3, which includes psychoeducation about BDD, psychoeducation about anxiety, constructing a hierarchy, CBT formulation, goal setting, exposure and response prevention (ERP), behavioral experiments, evaluating thoughts, and mirror retraining 1.

Overall, the most appropriate next step in management for this patient is to prescribe fluoxetine and recommend cognitive behavioral therapy, as this represents the first-line treatment for BDD and has the potential to improve her symptoms and quality of life.

From the Research

Diagnosis and Treatment

The patient's symptoms, such as excessive concern about her appearance, avoidance of social activities, and depressed mood, suggest a diagnosis of body dysmorphic disorder (BDD) or major depressive disorder with a focus on appearance concerns.

• The patient's physical examination shows normally sized ears without significant protrusion, indicating that her concerns may be related to a distorted body image rather than an actual physical deformity.
• The patient's mental status examination shows a depressed mood, which is consistent with BDD or major depressive disorder.

Treatment Options

The most appropriate next step in management would be to address the patient's underlying psychological concerns.

• Option D, "Prescribe fluoxetine and recommend cognitive behavioral therapy," is supported by studies 2, 3, 4, 5, which suggest that selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, in combination with cognitive behavioral therapy (CBT), can be effective in treating depression and anxiety disorders, including BDD.
• Fluoxetine has been shown to be effective in treating major depressive disorder in adolescents 4 and has a relatively favorable side effect profile compared to other SSRIs 2.
• CBT can help the patient address her distorted body image and develop more adaptive coping strategies.

Rationale for Choosing Option D

The other options are not as appropriate because:

• Option A, "Explain the risks and benefits of cosmetic surgery to the patient," may not address the underlying psychological concerns and may even reinforce the patient's distorted body image.
• Option B, "Reassure the patient that her ears look normal," may not be effective in addressing the patient's concerns and may come across as dismissive.
• Option C, "Ask the patient to describe her appearance to herself while looking in a mirror," may be a useful therapeutic technique, but it is not a comprehensive treatment plan.
• Option E, "Ask the mother to describe her daughter's appearance in her presence," may not be relevant to the patient's treatment and may even be counterproductive.

Studies 3, 4, 5 support the use of SSRIs and CBT in the treatment of depression and anxiety disorders, including BDD, and suggest that this combination can be more effective than either treatment alone.