737176

research-article2017
CCSXXX10.1177/1534650117737176Clinical Case StudiesLe et al.

Article
Clinical Case Studies
2017, Vol. 16(6) 480­–496
Intensive Exposure and Response © The Author(s) 2017
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DOI: 10.1177/1534650117737176
https://doi.org/10.1177/1534650117737176
Dysmorphic Disorder With journals.sagepub.com/home/ccs

Comorbid Obsessive–Compulsive
Disorder and Major Depressive
Disorder

Thien-An P. Le1, Katie Merricks2, Joshua M. Nadeau2,3,

Amaya Ramos2, and Eric A. Storch2,3

Abstract
Body dysmorphic disorder (BDD) primarily onsets during adolescence, and symptoms typically
worsen when left untreated. Although use of cognitive-behavioral therapy (CBT) has established
efficacy for adults with BDD, there is limited research and few case studies to suggest the same
for adolescents and children. The present case describes the implementation of intensive (daily)
treatment for Erin (pseudonym), a 17-year-old Caucasian female with primary BDD, as well as
comorbid obsessive–compulsive disorder (OCD) and major depressive disorder (MDD), who was
initially nonresponsive to outpatient supportive psychotherapy and pharmacotherapy. Treatment
consisted of exposure and response prevention (ERP), concurrent with behavioral activation (BA).
At discharge, Erin’s total score on the Children’s Yale–Brown Obsessive Compulsive Scale–Self-
Report version (CY-BOCS-SR) decreased from 32 (extreme severity) at pretreatment to 11 (mild
severity), as well as demonstrating improvement on other self-report measures.
Despite significant reductions in ritual engagement, Erin’s symptoms never fully remitted.
Based on telephone contact with her mother, Erin discontinued ERP upon returning home,
where treatment gains were not maintained and symptoms returned to baseline severity. Thus,
this case study demonstrates the effectiveness of intensive ERP for adolescent BDD, as well
as demonstrating the lack of gain durability associated with withdrawing early from treatment.
Furthermore, this case demonstrates that withdrawal from ERP prior to complete remission
may lead to a resurgence of symptoms, thus making previous progress obsolete.

Keywords
exposure and response prevention (ERP), intensive ERP, cognitive-behavioral therapy (CBT),
intensive CBT, adolescent body dysmorphic disorder (BDD), comorbid BDD, outpatient
nonresponder.

1University of Central Florida, Orlando, USA

2Rogers Behavioral Health–Tampa, FL, USA
3University of South Florida, St. Petersburg, USA

Corresponding Author:
Eric A. Storch, Rothman Center for Neuropsychiatry, University of South Florida, 880 6th Street South, Box 7523, St.
Petersburg, FL 33701, USA.
Email: estorch@health.usf.edu
Le et al. 481

1 Theoretical and Research Basis for Treatment

Body dysmorphic disorder (BDD) is characterized by preoccupation with one or more perceived
defects or flaws in physical appearance. Preoccupations include beliefs of being unattractive,
imperfect, abnormal, or deformed (Bjornsson et al., 2013; Fang & Wilhelm, 2015). However, the
perceived flaws are not observable or appear slight to others. Prevalence in the United States for
adults is 2.4% with a mean age of onset of 16 years, and a modal age of onset being approxi-
mately 12 to 13 years (Bjornsson et al., 2013). The course of BDD is chronic, with symptoms
unlikely to remit in the absence of evidence-based intervention (Hollander & Hong, 2016; Thiele
& Hamalian, 2015).
Compared with individuals with obsessive–compulsive disorder (OCD), persons with
BDD generally exhibit poorer insight and increased suicidal ideation (Fang & Wilhelm,
2015). Moreover, BDD diagnosis also is associated with increased risk for comorbid major
depressive disorder (MDD), alcohol and substance use disorder (Bjornsson, Didie, & Phillips,
2010), social phobia (Phillips et al., 2010), and anorexia nervosa or bulimia nervosa (Thiele
& Hamalian, 2015). Psychosocially, individuals with BDD often present with overall impaired
quality of life, as well as deficits in social and emotional functioning (Schneider, Turner,
Mond, & Hudson, 2017). Individuals with BDD are more likely to seek consultation and/or
receive cosmetic surgeries, dermatologic procedures, or dental work to address perceived
flaws or imperfections (Fang & Wilhelm, 2015). However, such attempts to mitigate preoc-
cupations are typically unsuccessful as procedures do not alleviate pathological preoccupa-
tion (Fang & Wilhelm, 2015).

Treatment Options
To date, there is limited support validating (a) efficacy of exposure and response prevention
(ERP) for adolescent BDD and (b) efficacy of intensive treatment for individuals who are non-
responders to standard outpatient treatment. Currently, few studies have established efficacy of
the former step by investigating the use of ERP for adolescent BDD. One pilot randomization
trial, including thirty 12- to 18-year-old patients diagnosed with BDD, was conducted in the
United Kingdom. Cognitive-behavioral therapy (CBT) was administered via a standard outpa-
tient treatment schedule, with 14 sessions over a 4-month period and treatment was compared
with a control condition, consisting of psychoeducation. Not only did this study conclude that
an adapted CBT was superior to a control condition (d = 1.13), but parents and patients also
reported that the treatment was highly acceptable and helpful in alleviating symptoms (Mataix-
Cols et al., 2015).
In the United States, an open trial was conducted to test the efficacy of a newly developed
modular CBT treatment protocol for adolescents with BDD, which also followed a standard out-
patient treatment schedule (Greenberg, Mothi, & Wilhelm, 2016). Parallel to the study conducted
in the United Kingdom, Greenberg et al. (2016) also demonstrated that an altered CBT for BDD
was feasible and effective for treating adolescents with BDD, with 100% of treatment completers
reporting a decrease in BDD and depressive symptoms (d = 8). Findings support the implementa-
tion of CBT for a psychopathology where the modal age of onset is 12 to 13 years of age
(Bjornsson et al., 2013). However, outside of case reports (Grabill, Storch, & Geffken, 2007;
Pence, Storch, & Geffken, 2010; Storch, Bagner et al.,2007; Storch et al.,2010) there are few data
on the efficacy of CBT for nonresponders to prior intervention. While these preliminary data are
promising, a number of youth did not respond to standard CBT (Grabill et al., 2007; Pence et al.,
2010; Storch, Geffken et al.,2007; Storch et al.,2010) and data among adults suggest modest rates
of nonresponse and partial response (Khemlani-Patel, Neziroglu, & Mancusi, 2011; McKay,
1999).
482 Clinical Case Studies 16(6)

Intensive Treatment
Moreover, while few studies establish efficacy of standard outpatient treatment for most adoles-
cents with BDD (Aldea, Storch, Geffken, & Murphy, 2009; Greenberg et al., 2016; Krebs, Turner,
Heyman, Mataix-Cols, 2012; Mataix-Cols et al., 2015), not all individuals respond to such treat-
ment, thus warranting further studies investigating efficacy of intensive (daily) CBT. Despite the
lack of randomized control studies, a recent case study demonstrated the efficacy of intensive
(twice weekly) multicomponent treatment for adolescent BDD with comorbid MDD (Burrows,
Slavec, Nangle, & O’Grady, 2013). However, one treatment barrier the authors disclosed included
that the patient expressed low motivation to engage in treatment, addressed with motivational
interviewing (MI). The authors concluded that their case was consistent with Phillips’ (2005)
hypothesis that it may be difficult to obtain motivation in severe cases of BDD and further sug-
gest that meaningful change is not likely to occur in the absence of motivation. While the patient
made significant improvements, the authors disclosed that at 3-month follow-up, the patient
reported mild symptom severity on various assessments of BDD symptoms (Burrows et al.,
2013).
Given the lack of controlled studies reporting efficacy of intensive treatment for adolescent
BDD, examining treatment among adult populations warrants consideration. Among adults, such
studies exist for OCD (Foa et al., 2005) and BDD (Khemlani-Patel et al., 2011; McKay, 1999)
concluding that intensive treatment for adults with OCD and BDD have similar or even greater
efficacy to weekly sessions (Foa et al., 2005; Khemlani-Patel et al., 2011; McKay, 1999).
However, the same has yet to be examined for BDD in youth.
In summary, intensive (daily) massed treatment might be (a) better suited for patients with
more severe symptomology and functional impairment (Storch, Gelfand, Geffken, & Goodman,
2003), (b) particularly useful when patients require enhanced motivation (Burrows et al., 2013;
Grabill et al., 2007), and (c) based on case studies, when patients desire rapid symptom relief
(Grabill et al., 2007). While there is support for the effectiveness of intensive CBT among ado-
lescents with OCD (Grabill et al., 2007; Pence et al., 2010; Storch, Bagner et al.,2007; Storch,
Geffken et al., 2007;Storch et al.,2010), the current case study could bridge the gap by extending
support for intensive CBT with adolescent BDD.

2 Case Introduction
In this report, we describe the treatment of Erin, a 17-year-old female with BDD (primary) and
comorbid OCD and MDD. Erin reported struggling with symptoms of BDD for 2 years mani-
festing as preoccupations of having flawed and imperfect eyebrows and ritualistic behaviors
regarding her eyebrows. In response to such preoccupations, Erin’s typical day consisted of
repeatedly applying makeup to her natural eyebrows each morning until she felt that her eye-
brows appeared “acceptable.” Prior to seeking treatment, Erin and her mother reported rituals
lasting approximately 3 hr per day, with intermittent occurrences of having 7 hr rituals involving
self-grooming.
A risk assessment revealed that no suicidal/homicidal ideation, plan, or intent was endorsed.
Erin also denied any history of childhood trauma, including any physical, sexual, and/or emo-
tional abuse, which was corroborated by Erin’s mother.

3 Presenting Complaints
Erin presented with symptoms of BDD where her preoccupations focused on the appearance of
her eyebrows. At the time of intake, Erin reported being late for appointments and school due to
an excessive time spent performing rituals. Tardiness due to completing rituals became so
Le et al. 483

severe that she would arrive to school several hours late or miss social gatherings altogether.
Academic impairment was evident as Erin’s grades significantly decreased due to her inability
to attend school. Furthermore, Erin reported feeling overwhelmed and distressed when tasked
with completing makeup work. She also exhibited social impairment due to avoidance of going
out in public. On the rare occasion that Erin coordinated social gatherings, she often experi-
enced difficulty making it to such appointments due to “getting stuck” in the bathroom when
engaging in rituals. Thus, she no longer could engage in activities previously enjoyable, such as
extracurricular dance rehearsals or spending time with friends. Erin’s mother corroborated
Erin’s self-reports, stating that Erin exhibited difficulty motivating herself to do anything but
her rituals. According to Erin and her mother, interpersonal impairment was also present within
the family as Erin’s symptoms often led to arguing between her and her parents, thus causing
strain in the relationship.
Erin reported attending supportive psychotherapy one to two sessions per week for approxi-
mately 4 months concurrently with pharmacological treatment. Regarding medication, Erin was
previously prescribed sertraline (100 mg, q.i.d.) and Melatonin (5 mg, q.d.) to address sleep dif-
ficulties. Erin and her mother reported medication compliance for a duration of 2 years. In gen-
eral, Erin exhibited limited response to the combination of supportive therapy and
psychopharmacology, thus requiring more intensive intervention.

4 History
Erin’s peri- and postnatal history and her developmental history were unremarkable. Erin’s
mother reported that she met her developmental milestones on time, made appropriate eye con-
tact, exhibited appropriate use of and reaction to gestures, and bonded well socially as an infant
and toddler. Overall, Erin’s mother reported that Erin was an “easy-going infant” who was easily
comforted.
Psychosocially, Erin was an “A”-level high school student and did not have any behavioral
problems at school. In fact, she reported that she enjoyed going to school, particularly to see her
friends, although this had changed over the past 2 years. Although Erin denied having any diffi-
culties making and maintaining friends, her BDD symptoms interfered significantly with her
ability to socialize (e.g., being unable to make it to social gatherings, dance rehearsals, and
school).
Erin’s mother reported a family history of mental illness. More specifically, Erin’s mother
reported being diagnosed with OCD and depression. In addition, Erin’s mother reported that two
of her biological brothers (Erin’s uncles) were diagnosed with OCD and that Erin’s maternal
grandfather was diagnosed with alcohol use disorder.

5 Assessment
Prior to treatment, Erin and her mother/father completed a comprehensive assessment, which
included an unstructured diagnostic interview, self-report measures, and parent-report measures
to assess the nature and severity of presenting symptoms, as well as the level of functional impair-
ment. The assessment battery for obsessive and compulsive symptoms consisted of Children’s
Yale–Brown Obsessive Compulsive Scale (CY-BOCS; Scahill et al., 1997). The CY-BOCS is the
most widely used clinician administered checklist and severity ratings of obsessions and compul-
sions. The clinician administered checklist and severity ratings scale is often paired with a self-
report checklist, where clinicians assess presence and severity of reported symptoms using a
5-point Likert-type scale (0 = none, 1 = mild, 2 = moderate, 3 = severe, and 4 = extreme).
Regarding obsessions, clinicians also use a 5-point Likert-type scale to assess an individual’s
ability to control them (0 = complete control, 1 = much control, 2 = moderate control, 3 = little
484 Clinical Case Studies 16(6)

control, and 4 = no control). Scores on the CY-BOCS range from 0 to 40, with higher scores
indicating greater severity. Ratings on the clinician administered CY-BOCS were made consider-
ing Erin’s BDD symptoms, with a total score of 36, indicating extreme symptom severity.

Self-Report Measures
Children’s Yale-Brown Obsessive Compulsive Scale Child/Adolescent Self-Report Symptom Checklist (CY-
BOCS-CA-SR).  The CY-BOCS-CA (Scahill et al., 1997) self-report questionnaire assesses pres-
ence and severity of obsessions and compulsions. The self-report version consists of the same
questions and scoring format as the clinician administered CY–BOCS (4-point Likert-type scale).
Scores range from 0 to 40, which higher scores indicating greater severity. Consistent with Erin’s
score on the CY-BOCS, she indicated a total score of 32 on the self-report questionnaire, which
also fell within the extreme symptom severity range.

Child Anxiety Sensitivity Index (CASI).  The CASI (Silverman, Fleisig, Rabian, & Peterson, 1991)
assesses how aversively patients view anxiety symptoms. On the CASI, children are asked to
respond to items like, “it scares when I feel like I am going to throw up,” by choosing either none
(1), some (2), or a lot (3) to each item. CASI scores range from 18 to 54 and are elevated in chil-
dren with anxiety disorders, where higher total scores indicate greater anxiety sensitivity (Peter-
son & Reiss, 1987). Erin’s pretreatment CASI score was 40, suggesting that Erin is more sensitive
to symptoms of anxiety than most other children.

Liebowitz Social Anxiety Scale for Children/Adolescents (LSAS-CA).  The LSAS-CA (Masia-Warner
et al., 2003) assesses anxiety experienced and avoidance in response to a range of social situa-
tions and performance interactions. Respondents are instructed to rate each item using two
4-point Likert-type scales for fear and avoidance from 0 (none), 1 (mild), 2 (moderate), and 3
(severe), where the summative total score ranges from 0 to 144 with higher scores reflecting
increased severity. Erin’s LSAS-CA pretreatment score of 93 exceeded the suggested cutoff of
29.5 (when comparing to those with other anxiety disorders; Masia-Warner et al., 2003), suggest-
ing that she was experiencing significant social anxiety.

Patient-Reported Outcomes Measurement Information System–Depression (PROMIS-D). The

PROMIS-D (National Institutes of Health, 2013) is a 14-item questionnaire that measures
depressive symptoms where an average total score for the United States general population is
50, with higher scores indicating greater severity. Respondents are instructed to rate several
items corresponding with symptoms of depression using a 5-point Likert-type scale (1 =
never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = always). Erin’s pretreatment score of 61
indicates that her depressive symptoms exceed the average by 1 SD, suggesting significant
depressive symptoms.

Assessment of BDD
During the clinician administered CY-BOCS, Erin reported experiencing symptoms since the age
of 15 years. At the time of intake, her primary obsession focused on the appearance of her eye-
brows. Erin reported spending a significant portion of the day thinking about her eyebrows spe-
cifically that they had to be a “certain” way. Her compulsions included repeatedly applying
makeup to her eyebrows until they felt “just right.” Erin reported that her rituals also included
grooming behaviors such as tweezing and spooling her eyebrows to enhance their appearance.
Rituals involving her eyebrows, reportedly, averaged approximately 3 hr a day, although occa-
sionally reaching a peak of 7 hr prior to seeking treatment.
Le et al. 485

Erin reported significant distress and interference from her intrusive thoughts. Examples of
impairment included difficulty arriving to school on time, completing tasks and homework
assignments in a timely manner, and engaging in hobbies and activities she typically enjoyed.
Erin and her mother also reported a strained relationship within the family due to arguments often
stemming from discussions of her condition and difficulties.

Assessment of Other Psychopathology

At the time of presentation, Erin also endorsed symptoms of OCD centered on “just right”
feelings. Although she was unable to identify a specific fear that drove the compulsions, she
disclosed urges to engage in repeating rituals until feeling “just right.” Such rituals included
excessive list making, mental rituals, ordering/rearranging, rereading, and rewriting which
occurred each time she was tasked with completing chores or academic assignments. Erin
reported that engagement in such behaviors were aimed toward reducing anxiety; however,
she would become distressed at her inability to cease her rituals, which lasted up to 3 hr each.
Academic interference was considerable as schoolwork became increasingly difficult,
requiring more time to complete assignments, which exacerbated feelings of distress.
Interference was observed consistently at home. For example, when tasked with cleaning her
room, Erin reported feeling compelled to create a to-do list, which would become excessive
to the point where Erin would not have time to clean her room. Given that these set of symp-
toms were unrelated to perceived bodily flaws or her physical appearance, Erin also met
criteria for OCD.
Erin endorsed depressive symptoms (e.g., anhedonia, decreased energy, sleep disturbances,
difficulty concentrating, and difficulty making decisions), which frequently waxed and waned
for approximately 2 years. Prior to treatment, Erin reported difficulty motivating herself to do
anything unrelated to her rituals, which led to impairment in academic and social functioning as
well as decreasing engagement in extracurricular hobbies. Erin reported that she initially lost
interest in extracurricular activities due to the anxiety of being unable to make it to appointments
on time when engaging in rituals, which then exacerbated depressive symptoms.

6 Case Conceptualization
Based on self- and parental-report, and clinician interviews, Erin met criteria for BDD, OCD, and
MDD based on Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5;
American Psychiatric Association, 2013) criteria. With respect to etiology, it appeared that Erin’s
MDD occurred secondary to her BDD and may have initially manifested as avoidance upon
becoming anxious about the appearance of her eyebrows.
Erin’s symptoms of BDD are consistent with findings of extant studies examining etiologic
conceptualizations of development. Buhlmann and Wilhelm (2004) propose cognitive mecha-
nisms, such as biases in the perception, interpretation, and memory of appearance-relevant stim-
uli contribute to the maintenance of BDD. In addition, neuropsychological studies demonstrate
that individuals with BDD tend to overly focus on details of visual and verbal stimuli, compared
with processing stimuli holistically (Deckersbach et al., 2000; Feusner, Townsend, Bystritsky, &
Bookheimer, 2007; Kerwin, Hovav, Hellemann, & Feusner, 2014). By overly focusing on such
details, inidividuals with BDD, thus, selectively attend to specific aspects of their appearance or
minor flaws (Wilhelm, 2006). Furthermore, Wilhelm, Phillips, and Steketee (2012) discuss that
interpretative bias combined with traits of perfectionism, overestimation of attractiveness of oth-
ers, rejection sensitivity, and overestimation of the importance of beauty contribute to develop-
ment of BDD.
486 Clinical Case Studies 16(6)

In line with this conceptualization, it was hypothesized that Erin feared being judged as inad-
equate or imperfect by others. Although Erin lacked insight in specifically describing her core
fear, Erin’s rituals demonstrated the need to overly focus on specific aspects or minor flaws.
For instance, Erin’s obsession of having “just right” eyebrows, the need to be comprehensive
in including minute tasks on “to-do” lists, and/or writing things “perfectly” may be considered
manifestations of this core fear. Furthermore, although Erin did not meet diagnostic criteria for
social anxiety disorder, such symptoms may be used as further support for the theorized core fear,
of being evaluated or judged by others.

7 Course of Treatment
Treatment Selection
Based on the results of Erin’s clinical assessment, self-report, and parent-reports, it was deter-
mined that she would benefit from an individualized treatment plan utilizing ERP. However, Erin
previously was nonresponsive to standard outpatient and pharmacological treatment, thus war-
ranting a more intensive treatment approach. Given that Erin also presented with depressive
symptoms, it was also determined to include behavioral activation (BA) in her treatment plan.

Treatment Plan Structure

Erin completed 6 weeks of intensive treatment in a partial hospitalization program (PHP) where she
received 5 hr of individual and family-based CBT in conjunction with 1 hr of group therapy each
day. As part of an integrated treatment facility, Erin also received two sessions with a board-certified
child/adolescent psychiatrist and one family counseling session with the family therapist each week.
A comprehensive treatment plan was devised to target symptoms of BDD, OCD, and MDD. At
treatment onset, Erin and her family were provided psychoeducation about anxiety as well as the
rationale behind ERP and BA. The overall treatment plan consisted of assigning daily exposures to
target Erin’s obsessions and compulsions, while monitoring the occurrence of rituals (e.g., checking
eyebrows, reapplying makeup, seeking reassurance, and requesting accommodations) throughout
treatment. Overall, Erin’s goal for treatment was to reduce overall distress and frequency of rituals.

Treatment of BDD Symptoms

The primary focus of treatment targeted Erin’s BDD symptoms where assigned exposures gradu-
ally increased in difficulty. At the start of treatment, Erin identified several challenges and ranked
them by level of difficulty on a scale of “0” through “7,” where “0” indicated no difficulty and
“7” indicated most extreme difficulty imaginable. Items on Erin’s hierarchy included exposures
such as standing in front of a mirror while refraining from tweezing, completing care of her eye-
brows in 1 hr, viewing pictures and tutorials of grooming eyebrows while refraining from check-
ing her own eyebrows, using natural and unnatural eyebrow colored pencils, and walking in
public with a “unibrow,” among many others. Exposures completed in clinic were therapist
assisted, while exposures assigned for homework were parent assisted or completed indepen-
dently. Once Erin exhibited competency in completing exposures with minimal difficulty or
anxiety, she was instructed to continue repeating assignments individually.

Treatment of OCD Symptoms

Treatment for Erin’s OCD symptoms also included ERP, where exposures targeted reading and
writing assignments while refraining from rereading or rewriting and limiting list making.
Le et al. 487

Exposures were assigned in conjunction with BDD exposures and were completed with identical
instructions.

Treatment of MDD Symptoms

According to Phillips and Stout (2006), most patients with BDD have some degree of depression,
where increased symptom severity of one psychopathology is related to the increase in the other.
Typical treatment for major depression included BA, a well-established cognitive-behavioral
treatment which uses behavioral strategies, such as activity scheduling and cognitive strategies,
such as cognitive restructuring, to engender motivation toward a more fulfilling lifestyle (Martell,
Dimidjian, & Herman-Dunn, 2013).

Sessions 1-5, Week 1

Regarding Erin’s BDD symptoms, exposures planned for the first week of treatment consisted of
items Erin ranked as being low (“1” and “2”) on her hierarchy. While engaging in exposures, Erin
was instructed to resist her rituals. The first week of exposures included tasks such as writing and
sharing a worry script about refraining from her rituals, removing the makeup from her eye-
brows, showing peers her eyebrow makeup, standing in front of a mirror while refraining from
tweezing, buying new eyebrow pencils of unnatural colors, and taking pictures of herself without
eyebrow makeup, among many others. During each exposure, Erin was instructed to record her
Subjective Units of Distress (SUDs) using an 8-point Likert-type scale where “0” indicates no
anxiety and “7” indicates most extreme levels of anxiety. Erin was also instructed to repeat expo-
sures until her distress declined at least 50% of her peak SUDs ratings.
To address Erin’s OCD symptoms, exposures planned for the first week included exposure to
scripts of feared outcomes (e.g., not constructing comprehensive to-do lists, not doing tasks per-
fectly), reading without rereading, and writing without rewriting. Erin was instructed to record
and monitor her SUDs in the same fashion as with her BDD symptoms.
Erin was also assigned tasks consistent with BA. During the first week of treatment, Erin was
provided treatment rationale for BA and instructed to clarify core values and activities targeted
toward reaching such goals. Thus, Erin was assigned homework that she and her parents con-
structed together and were consistent with attaining her identified goals and core values.
Additional BA methods frequently incorporated into Erin’s treatment included cognitive restruc-
turing to address cognitive errors regarding her appearance and completion of thought records to
address automatic thoughts. Treatment aimed toward alleviation of OCD-related and depressive
symptoms remained constant throughout the course of treatment.

Sessions 6-10, Week 2

The second week of treatment consisted of gradually progressing through Erin’s hierarchy, with
increasing difficulty and anxiety. Regarding Erin’s BDD symptoms, treatment was geared toward
response prevention by decreasing the amount of time spent completing her eyebrow makeup.
During Session 7, Erin was instructed to complete her eyebrow makeup within 45 min. When
doing so, she reported initial moderate anxiety (“4”), which decreased to a “0” within the expo-
sure. Additional exposures assigned during the second week of treatment included hanging pic-
tures of “imperfect” eyebrows around her room, participating in activities where her eyebrows
may get wet (e.g., water balloon fights and swimming), using blue eyebrow pencil and walking
around the clinic, drawing a “unibrow” on herself and walking around the clinic, decorating her
eyebrows with various cosmetic accessories, and spooling her eyebrows backward, among other
exposures.
488 Clinical Case Studies 16(6)

During the second week of treatment, Erin began demonstrating resistance to treatment and
attempted to avoid exposures due to the increasing level of difficulty. Exposures that required
encouragement to complete included water activities, taking pictures of herself while wearing a
“unibrow,” and decorating her eyebrows with cosmetic accessories. In the event of resistance to
exposures, clinicians implemented strategies of MI to assist Erin in maintaining motivation.
Given that comorbid depression is common among individuals with BDD, particularly as treat-
ment progresses and Erin began confronting her fears while refraining from rituals, Erin’s inter-
mittent motivation was anticipated. At such moments, clinicians implemented several strategies
consistent with MI such as affirming her self-efficacy, summarizing her achievements, clarifying
her goals and values, and challenging her with open-ended questions to identify treatment barri-
ers. Although Erin appeared distressed, she often engaged with clinicians during MI and conse-
quently completed her exposures.

Sessions 11-16, Week 3

Treatment for BDD continued to target decreasing time to complete eyebrow makeup. On Session
11, Erin was instructed to complete her eyebrow makeup in 30 min, which was ranked as a “7”
on her hierarchy. Given the level of difficulty, Erin exhibited severe distress and was ultimately
unable to complete the exposure, even when clinicians implemented MI. Erin was reassigned the
exposure the following day and was successful in completing it, reporting a “5” at the start of the
exposure and ending at a “2.” Erin was assigned to repeat the exposure for homework and in
clinic until she demonstrated between-session habituation, with a peak SUDs of “2” or “3.”
Exposure tasks that Erin was successful in completing during the third week of treatment
included wearing a “unibrow” and greeting people in public, taking pictures of herself with a
“unibrow” and posting it on social media, wearing blue eyebrow pencil, and wearing no eyebrow
makeup in the clinic.

Sessions 17-21, Week 4

By the fourth week of treatment, Erin was successful in completing her eyebrow makeup in 5 min
with a peak SUDs of “2.” In addition, Erin could brush her eyebrows backward and “mess” them
up, as well as allowing others to complete her eyebrow makeup, with low anxiety (“3”).
Supplementary exposures completed during the fourth week of treatment included receiving
feedback on her eyebrows from cosmetic specialists, completing her eyebrow makeup with an
audience, and cutting her eyebrows “imperfectly.” Erin could complete exposures despite some
resistance and demonstrated appropriate habituation.

Sessions 22-27, Week 5: Treatment of Depressive Symptoms and Social Anxiety

Given that Erin made considerable improvement in her anxiety regarding her eyebrows, treat-
ment shifted more toward targeting Erin’s depressive symptoms starting Week 5. Consistent with
BA, clinicians assisted Erin in activity scheduling where she was assigned homework geared
toward increasing social engagement and to strengthen her interpersonal relationships. Such
assignments included calling/texting hometown friends and spending time outside of the hotel
room with her family. Clinicians also challenged Erin to learn various dance moves and routines,
a hobby she considered a core value despite avoiding dance rehearsals and recitals. Behavioral
assignments were also in addition to being provided aspects of cognitive restructuring aimed
toward helping Erin develop more accurate and helpful thoughts and core beliefs. Tools such as
thought records were provided and discussed throughout treatment to assist Erin in identifying
automatic thoughts and cognitive errors.
Le et al. 489

Table 1.  Biweekly Self-Reported Assessment Scores.

Measure Admission 2-week 4-week Discharge

Time on eyebrows (minutes) 180-240 45 25 3
CY-BOCS-SR 32/40 24 18 11
CASI 40/54 42 39 37
LSAS-CA 93/154 83 61 62
PROMIS-D 61.1/100 63.1 52 61.1

Note. CY-BOCS-SR = Children’s Yale–Brown Obsessive Compulsive Scale–Self-Report; CASI = Child Anxiety
Sensitivity Index; LSAS-CA = Liebowitz Social Anxiety Scale for Children/Adolescents; PROMIS-D = Patient-Reported
Outcomes Measurement Information System–Depression.

Figure 1.  Biweekly monitoring of time spent on completing eyebrows.

In addition, treatment shifted toward exposures for social anxiety. Exposures included giving
speeches/presentations to groups, receiving feedback on drawings, showing peers and staff her
dance videos, and wearing silly outfits. Social anxiety exposures were repeatedly assigned until
she demonstrated within- and between-session habituation.

Self-reported progress and outcome.  Erin completed biweekly self-report assessments throughout
the course of treatment and at discharge. In general, Erin exhibited improvement on measures of
obsessive and compulsive symptom severity, sensitivity to anxiety and social anxiety, but
reported no change in depressive symptoms (Table 1).
Erin reported marked improvement in time spent completing her eyebrow makeup. Prior to
treatment, Erin reported spending an average of 3 to 4 hr (210 min, see Figure 1) in the bathroom
attending to her obsessions and rituals. Erin made the largest improvement in this area during the
second week of treatment (decrease of 165 min), and by discharge only required 3 min. Despite
her marked reductions in time spent on rituals, it should be noted that Erin did not reach full
remission and still engaged in her ritual daily.
Consistent with the decreased time spent on rituals, Erin also reported marked improvement
on her self-report measure of BDD and obsessive–compulsive symptom severity. Based on the
CY-BOCS self-report questionnaire, Erin’s total score decreased from 32 (extreme severity) at
pretreatment to an 11 (Mild severity) at discharge, representative of a substantial decrease in
490 Clinical Case Studies 16(6)

Figure 2.  Biweekly CY-BOCS-SR total scores.

Figure 3.  Biweekly self-reported submission to rituals.

symptoms (Figure 2). Consistent with her response on the CY-BOCS self-report questionnaire,
Erin reported fewer occurrences of rituals, with the greatest decline observed in overall eyebrow
checking (Figure 3). Although there was a general decline in ritual engagement, it is likely that
Erin underreported incidences of reassurance seeking behaviors during Week 1 of treatment.
Perhaps a potentially more accurate method of assessing reassurance seeking behaviors would
have been to request that the parents monitor.

8 Complicating Factors
Despite Erin’s marked improvement throughout the course of treatment, a few complicating fac-
tors and treatment considerations are noteworthy for discussion. According to extant research,
severely depressed OCD patients respond less frequently to treatment than OCD patients who are
Le et al. 491

not severely depressed (Storch et al., 2008a). One explanation of this effect may be that the pres-
ence of comorbid MDD symptoms often leads to decreased hope that treatment may work and/
or decreased motivation/energy to engage in exposures (Storch et al., 2008a). Although there are
limited studies examining this in BDD patients, it might be hypothesized to observe a similar
effect due to the symptom overlap with OCD. For instance, Erin often reported not wanting to
leave her bed or hotel room and preferred to sleep throughout the day, consequently making it
difficult for her to engage in ERP. Consistent with case study conclusions reported by Burrows
et al. (2013), it is evident that additional therapeutic techniques, such as MI, are required to
enhance treatment compliance when motivation to engage in treatment is low.
It should be noted that based on telephone correspondence with Erin’s mother, Erin
relapsed virtually to baseline upon returning home. Erin, reportedly, discontinued any main-
tenance of ERP after discharge and gradually stopped attending sessions with her outpatient
therapist. One interpretation of this outcome involves the consideration that, despite Erin’s
marked gains during treatment, at discharge, she was still engaging in rituals nearly every day,
meaning that she never attained full remission of symptoms. This is an important aspect when
considering that adults with OCD are more vulnerable to relapse if they experience partial
remission versus full remission (70% vs. 45%; Eisen et al., 2013). And in BDD patients, indi-
viduals who completed a treatment program that emphasized relapse prevention by imple-
menting self-initiated exposures were more likely to maintain treatment gains than individuals
who did not (McKay, 1999).
For example, Whiteside and Abramowitz (2006) demonstrate this effect through a case of an
adolescent diagnosed with OCD who participated in an intensive PHP treatment program. While
Whiteside and Abramowitz (2006) report that the adolescent responded well to treatment and
reported a decrease on the CY-BOCS from pretreatment to posttreatment (27, severe, to 10,
mild), the patient did not attain full remission and relapsed upon discharge. Thus, the case study
reported by Whiteside and Abramowitz (2006) emphasizes the importance of continuing ERP
upon returning home, especially when the patient fails to attain full remission.
Moreover, Erin’s medication changes may also have influenced her improvement throughout
treatment. Given limited response prior to treatment initiation, it was recommended that Erin
alter her medication, transitioning from sertraline (100 mg, q.i.d.) to escitalopram (10 mg, q.i.d.)
instead. During the titration process, Erin may have experienced negative side effects while par-
ticipating in intense exposures with unstable medication, thus possibly affecting her treatment
compliance and motivation. During the medication transition, Erin reported suicidal ideation,
which subsided upon medication stabilization. While Erin experienced such ideation, BDD and
OCD exposures were limited to assignments that Erin had previously demonstrated efficacy in,
rather than assigning new exposure tasks.

9 Access and Barriers to Care

In addition to the above complicating factors, Erin had somewhat poor insight regarding her
symptoms and was unable to verbalize the stem of her anxiety. Several studies support that
insight is poorer in BDD than in OCD (McKay, Neziroglu, Yaryura-Tobias, 1997) and that there
is an impact of insight on treatment outcome among children with BDD (Eisen, Phillips, Coles,
& Rasmussen, 2004). Furthermore, patients who lack the ability to consider their thoughts and
behaviors as irrational also lack the ability to challenge them, leading to worse prognosis
(O’Dwyer & Marks, 2000). Contrastingly, patients with excellent insight tend to have favorable
outcomes in psychotherapy (Storch et al., 2008b). Thus, parallels can be drawn between the
extant literature and the current case study where Erin’s poor insight served as a barrier to her
care, thus likely diluting her response to treatment.
492 Clinical Case Studies 16(6)

10 Follow-Up
Over the course of treatment, Erin demonstrated marked improvement regarding her BDD and
OCD symptoms. Overall, Erin considered the decrease in the amount of time spent on her eye-
brow rituals her greatest improvement from treatment. Furthermore, while engaged in treatment,
Erin’s BDD and OCD symptoms were stabilized and alleviated in response to ERP. Consequently,
it was recommended that Erin continue self-initiated exposures to maintain gains, while receiv-
ing outpatient treatment to address remaining depressive symptoms. Although Erin experienced
some mitigation of depressive symptoms, progress was too inconsistent and not sustained
throughout intensive CBT.
Whiteside and Abramowitz (2006) report several benefits of an intensive PHP treatment pro-
gram but also state that a disadvantage regards generalizability back to the home environment.
Thus, approaching Erin’s discharge, care was coordinated with a local psychiatrist and outpatient
therapist. In addition to coordinating appointments after returning home, with consent, clinicians
consulted with the outpatient therapist to discuss details of the case via telephone. Discussions
included Erin’s treatment goals, achievements, and details regarding the treatment method imple-
mented. Based on telephone correspondence with Erin’s mother, however, Erin relapsed and her
BDD symptoms returned to baseline within 6 months of discharge. Given the resurgence of
severe symptoms, Erin was admitted to a local residential program to pursue further treatment.

11 Treatment Implications
This study has implications for clinicians and future clinicians seeking to treat youth with BDD,
particularly patients who are nonresponders to standard outpatient CBT. Although there is rich
support for efficacy of standard outpatient treatment for adult BDD, there is limited research and
case studies demonstrating the efficacy of ERP for adolescent BDD. Furthermore, while previous
studies support use of intensive CBT for adolescent OCD (Grabill et al., 2007; Pence et al., 2010;
Storch, Geffken et al.,2007; Storch et al.,2010), only one known case study demonstrates similar
efficacy for adolescent BDD (Burrows et al., 2013). Additional studies would be particularly
beneficial as there is currently a lack of “well-established” or “probably efficacious” treatments
as classified by Chambless and Hollon (1998) in their evaluation of empirically supported treat-
ments. Thus, this case study serves as a secondary demonstration of the efficacy of intensive
(massed) ERP in adolescent BDD with comorbid psychopathology. Not only did Erin’s symp-
toms remit while engaged in treatment, but there is also merit in considering the consequence of
disengaging from ERP early, as Erin relapsed to baseline when doing so.
It is also worthy to highlight the importance of this case study in demonstrating utility of
intensive CBT for BDD. Given that Erin was nonresponsive to standard outpatient and psycho-
pharmacology treatment, it became evident that a more comprehensive and intensive treatment
structure was warranted. The nature of a PHP allowed Erin to not only receive treatment for her
BDD, OCD, and MDD symptoms, but it also facilitated utilization of additional necessary ser-
vices. For example, having a child/adolescent psychiatrist, family counselor, education special-
ist, and group therapist on staff thus diminishes treatment barriers by increasing the ease of
access to enhance the quality of care. By eliminating treatment barriers to what some may con-
sider periphery resources, there is an extension of treatment, making it a more comprehensive
approach.
The current case study also serves as a demonstration of the importance of simultaneously
treating comorbid psychopathology. Overall, individuals with BDD typically require more inten-
sive strategies to encourage compliance in treatment (Burrows et al., 2013; Phillips, Didie, &
Menard, 2007) due to decreased motivation and energy (Storch et al., 2008a). Furthermore, treat-
ment techniques such as MI may be beneficial in enhancing compliance.
Le et al. 493

12 Recommendations to Clinicians and Students

The case study presented provides support for an intensive and comprehensive treatment
approach for adolescents with BDD and comorbid OCD and MDD. Although ERP for adult BDD
and OCD have been widely investigated, an emphasis on comorbid treatment merits consider-
ation, particularly in adolescent and when patients are nonresponsive to prior intervention.
Given that depression is highly comorbid with BDD, it is recommended that treatment of
BDD be provided concurrently with treatment for depression. However, when depressive symp-
toms become increasingly severe and begin to impair progress with BDD, a shift in the emphasis
of treatment should be considered. In the current case, Erin reported fluctuations in the severity
of depressive symptoms throughout the course of treatment. Occasional changes in medication
were recommended, and required Erin to wean off sertraline and switch to escitalopram (10 mg,
q.i.d) which may have influenced the fluctuations in depressive symptoms. Consequently, it was
imperative to continually monitor Erin’s depressive symptoms and employ therapeutic tech-
niques, such as cognitive aspects of BA and MI, to promote compliance with treatment. Ideally,
future treatments should consider the stability of a patient’s medication schedule before engaging
in exposure treatment.
Extant research supports that treating comorbid disorders simultaneously yields better out-
comes than when treating one disorder individually (Beidel, Frueh, Uhde, Wong, & Mentrikoski,
2011). The progress that Erin exhibited reflects the importance of treating such disorders simul-
taneously. Given that Erin attained marked improvements regarding BDD and OCD symptoms,
Erin was discharged to an intensive outpatient program where it was recommended she primarily
continue treatment for MDD, as well as for BDD/OCD symptom maintenance. However, addi-
tional methods might have been implemented prior to discharge to facilitate the transition back
home. Clinicians may have considered involving Erin and her family in telephone calls with the
outpatient therapist to ensure that everyone was on the same page regarding discharge instruc-
tions and expectations. Including Erin in her discharge planning might have empowered her to
continue attending therapy, knowing that there would be less of a gap in services and being able
to better anticipate what her outpatient sessions would be like.
In summary, consistent with extant literature, the current case exemplifies that (a) ERP is
effective for adolescent BDD when implemented (Aldea et al., 2009; Greenberg et al., 2016;
Krebs et al., 2012; Mataix-Cols et al., 2015); (b) severe comorbid depressive symptoms compli-
cate effectiveness of ERP potentially due to decreased hope and motivation to comply with treat-
ment (Storch et al., 2008a) and as such, treatments should be administered concurrently; (c)
individuals who do not attain full remission are more vulnerable to relapse (Burrows et al., 2013;
Eisen et al., 2013); and (d) continued ERP after discharge is necessary for maintaining treatment
gains (McKay, 1999).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies
Thien-An P. Le, MS, is currently completing her doctoral degree in Clinical Psychology at the University
of Central Florida. Her interests are in the nature and evidenced-based treatment of anxiety disorders, such
as post-traumatic stress disorder, social anxiety disorder, and obsessive-compulsive and related disorders
across the lifespan. Thien-An Le has published peer-reviewed journal articles and book chapters on these
topics.
Katie Merricks, PhD, is a clinician who specializes in evidence-based treatment for children and adoles-
cents with obsessive-compulsive disorder and other related disorders, anxiety disorders, and other anxiety
inducing difficulties. Dr. Merricks has worked in both partial hospitalization and intensive outpatient
programs.
Joshua Nadeau, PhD, is a clinician and researcher who specializes in the evidence-based treatment of anxi-
ety, mood, and obsessive-compulsive and related disorders in youth. In his research and clinical practice,
Dr. Nadeau focuses upon modifications to evidence-based treatment in order to address symptoms of
comorbid autism spectrum disorder (ASD) and other neurodevelopmental disorders. Dr. Nadeau has pub-
lished several peer-reviewed journal articles and book chapters on these topics, and is a frequent speaker for
professional development and/or training of interested providers.
Amaya Ramos, MD, is a board-certified child and adolescent psychiatrist who provides psychiatric ser-
vices for the intensive outpatient and partial hospital programs. Dr. Ramos is devoted to research as well as
to treating patients and has conducted studies in the area of pediatric psychopharmacology as it relates to
Tourette’s disorder, autism spectrum disorder and obsessive-compulsive disorder.
Eric A. Storch, PhD, is professor and All Children’s Hospital Guild Endowed Chair in the Departments of
Pediatrics, Health Policy & Management, Psychiatry and Behavioral Neurosciences, and Psychology at the
University of South Florida. Dr. Storch has received multiple grants from federal agencies for his research
(i.e., NIH, CDC), is a Fulbright scholar, and has published over 10 books and over 500 articles and chapters.
He specializes in the nature and treatment of childhood and adult obsessive-compulsive disorder and related
conditions, anxiety disorders, and anxiety among youth with autism.