John was a 30-year-old, single, African American medical student seeking treatment at an outpatient BDD clinic. John presented with concerns about short height, a protruding stomach, his body build, which he felt was not sufficiently muscular, and his skin color, which he believed was too dark. He reported spending 1-3 hours per day thinking about these appearance concerns. To decrease anxiety about these concerns, John spent two to three hours per day, six days per week, at the gym (formerly, he had spent as many as four hours a day at the gym). He took prohormones, a legal alternative to anabolic-androgenic steroids, to increase muscular growth. He also compared his body to others', measured his body parts of concern, and compulsively checked his appearance in mirrors. Due to his BDD symptoms, John also avoided leaving home and socializing with friends, did not have a romantic partner, and had increasing academic difficulties.
John discussed early in treatment that he grew up as "one of the few Black kids in a predominately White neighborhood." He reported that as a child his parents had encouraged him to associate with his White classmates, but not his Black classmates. In high school, he was involved in extracurricular activities, such as the speech and debate team, in which he was the only Black member, while the majority of his Black classmates participated on the football team. However, he reported that he was frequently the target of teasing from his White peers. By avoiding associating with his Black classmates and being teased by his White classmates, John felt that he did not fit in with either group, and therefore did not develop a strong personal identity as an adolescent.
John also described a preoccupation with exercising and building muscle starting in early adulthood, as an attempt to fit in with the African American community in a way he was not able to in middle school and high school. However, because John believed that society viewed African American males as inherently unattractive, he felt he had to become extremely physically fit in order to be regarded as merely acceptably attractive. Thus, John's exercise served two purposes: to help him establish a place in the African American community and to overcompensate for what he believed was society's opinion of him, as inherently unattractive because of his race.
At his baseline assessment, John received a diagnosis of BDD with comorbid severe Major Depressive Disorder (MDD), which was secondary to his BDD. He had no family history of BDD and was not taking any psychiatric medications. John's baseline BDD-YBOCS score was a 37, indicating severe BDD symptoms. His BABS score was a 17, which indicates poor insight of BDD-related beliefs, and his BDI-II score was a 20, indicating moderate depressive symptoms.