A.D., a 21-year-old single female, a graduate, currently pursuing degree in education, staying with parents, hailing from a semi-urban background, belonging to middle socioeconomic status, presented with the complaints of fear of interacting with others - since early childhood, preoccupied about her appearance, figure, nose, hair, and complexion - for the past 8 years and excessive use of mobile phone for Facebook, WhatsApp, and taking selfies for the past 3 years. The symptoms had an insidious mode of onset, with continuous course and fluctuating progress. There was no specific precipitating factor. The client was apparently doing well till 2008, when she was 14 years old and was studying in high school. Though she was always a below-average student, she became extremely sensitive to her teacher's comments in tuition classes regarding her studies. She compared herself with other students and felt inferior.
There was a decline in academic performance because she found mathematics and science difficult. She used to cry a lot at home and told her parents that she did not want to study. She stopped going to tuition classes and school. A psychiatrist counselled her in the nearby city, and prescribed medication. With this, she somehow managed to pass high school. There was not much improvement in the symptoms for the next few years as she became preoccupied with her appearance that her nose was not sharp, she was not fair, and had a lot of pimples. This led to a number of consultations with dermatologists, repeated mirror gazing, reassurance seeking, mood fluctuations and attempts at self harm. They sought consultation from us at NIMHANS in May 2013 and was diagnosed as BDD and social anxiety disorder. She was treated with clomipramine 150 mg/day with lithium, sertraline, and risperidone being tapered off. Therapy sessions focused on psychoeducation, cognitive restructuring, mirror retraining, exposure, and response prevention. They returned to their hometown so that she could appear for her examinations. She visited us again in October 2013, as the symptoms worsened. There was again excessive preoccupation with her looks, repeated mirror gazing, reassurance seeking, handwashing, face washing, and demanding behavior. Clomipramine was increased to 200 mg. Therapy was initiated again mainly focusing on cognitive restructuring, mirror retraining, and exposure and response prevention. There was improvement in 2 months' time. Subsequently, the patient was followed up every 6 months for reviewing the medication.
On subsequent follow ups it was seen that she continued her preoccupation with her appearance (figure, nose, complexion, and hair), leading to checking the mirror every hour of the day. She avoided seeing mirrors in shops, restaurants, etc., with the fear that she might look bad in it and also avoided going out in day time. She was very particular about her clothes and wanted it to be the perfect fit. She used to spend a lot of time on changing her hairstyle throughout the day. She wanted to look good in order to gain social acceptance and also be liked on Facebook and WhatsApp (ends up using her phone most time of the day). She avoided social interactions and giving presentations as she feared negative evaluation by others over what she said. She started using Facebook when she was Class XI, but on reaching college 1st year, there was excessive use of Facebook and WhatsApp. She had been preoccupied since then, whether others like her photograph on Facebook and whether others chat with her. She also had made a group of unknown friends. She checked her phone every 10 min for any messages or notifications on a usual day. She keeps clicking selfies every 15-20 min, till she was satisfied with a photograph, and if not she changed her hairstyle and clicks again. She clicked more selfies at night, because according to her, she looked better at night time, rather than day time, as it magnified her flaws. Whenever her net balance was over, she demanded her mother to get it recharged immediately. She preferred chatting and being with others online, rather than interacting in the real world. She avoided face-to-face conversations, giving presentations, purchasing things from a shop, eating, talking on a phone in a public place with the fear of negative evaluation by others, and being subject to the scrutiny of others. Premorbid temperament revealed that she had a lot of demands and temper tantrums as a child. She was overactive and would spend more time in extracurricular activities than academics. She had always been a below-average student in school and had difficulty in making friends. Family history revealed that the client's father had frequent anger outbursts and used to hit the client whenever she became demanding. Mother on the other hand was permissive. Assessment revealed the presence of problematic use of internet (score of 60 on Internet Addiction Test), excessive use of mobile and Facebook on Problematic Mobile Phone Use Questionnaire and Facebook Intensity Questionnaire, moderate social phobia on Liebowitz Social Anxiety Scale indicating moderate social phobia (score 58), and the patient got moderate score in the domains of anxiety (score 14) and stress (score-20) on Depression, Anxiety and Stress Scale.
Therapy components in the initial phase included psychoeducation about BDD and the cognitive-behavioral aspects, tracking mirror and mobile use, monitoring her negative automatic thoughts, triggers, and identifying the cognitive errors. In the middle phase of therapy, the cognitive errors and dysfunctional negative thoughts were challenged and her beliefs about the importance of appearance were identified. She was also encouraged to participate in other recreational activities such as yoga, walking, drawing, and going to the library. Specific contract was made regarding her mirror and mobile use on a typical day. Initial goal was to delay the frequency of use. Mirror retraining was also done. Exposure and behavioral experiments were used to modify the underlying beliefs of importance of appearance and social acceptance.
The outcome of the therapy was positive. Fifteen sessions were carried out with the client. Mirror usage had reduced to 5-6 times/day though she still avoided seeing mirrors of shopping malls, vehicles, etc. Mobile use was also reduced to 2-3 h every day. The craving for the mobile phone/internet was still there, and whenever the mobile balance would get over, she wanted to recharge it immediately. She was able to challenge certain negative automatic thoughts, but practice was needed in developing more realistic alternative thoughts. She would have benefitted from exposure to various social situations which she avoids, but due to lack of time, only one or two situations could be practiced.