Psych CASC / OSCE · General adult psychiatry — OCRD
Explain BDD, CBT-BDD and SSRI to a patient — CASC communication station
MRCPsych/FRANZCP-style communication station: explain BDD, ERP-style CBT, SSRI timeline, anti-surgery advice, family accommodation, and safety-netting for mood/suicidality.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar in the outpatient clinic. [4]
Candidate instructions. Explain BDD in plain language, outline specialised CBT with exposure and response prevention elements, discuss a possible SSRI (e.g. fluoxetine) with delayed benefit and higher-dose rationale, advise against surgery as a cure, address partner reassurance/mirror collusion, and check understanding. The examiner plays the patient. [4][5]
Candidate scenario
Your patient meets criteria for BDD with fair-to-poor insight focused on the nose. You plan referral for CBT-BDD and discussion of fluoxetine starting at 20 mg orally daily with planned titration and early review. She fears CBT will force her to “look ugly forever” and believes one perfect rhinoplasty will end the problem. Her partner currently checks her nose each morning to “reassure” her. [1][2][3]
Marking domains
- Empathy, structure and agenda-setting
- Accurate plain-language model of BDD (appearance preoccupation → shame/anxiety → checking/camouflage → short relief)
- Clear CBT-BDD/ERP explanation (hierarchy, response prevention, homework)
- Medication discussion: start dose concept, higher-dose/longer trial rationale, delayed benefit, side-effects
- Explicit advice that surgery is not a psychiatric cure
- Family accommodation advice without blame
- Safety-net for worsening mood/suicidality
- Checks understanding / teach-back [4][5]
Reveal assessor key
Open and agenda-set. Name time; ask main fears (looking worse in therapy; missing the “surgical fix”; partner role). [4]
Explain BDD. “BDD is a recognised mental health condition where the brain locks onto a perceived appearance flaw that others see as minor or not there. Checking and camouflaging briefly reduce distress but keep the cycle going. It is not vanity or a character flaw.” [5]
Explain CBT-BDD. Therapy helps you gradually face mirrors and social situations while reducing checking, camouflage and reassurance, so the brain learns the anxiety falls without rituals. We use a step-by-step ladder — not the hardest step first. Evidence supports specialised CBT.[2][4]
Medication. An SSRI such as fluoxetine can reduce BDD intensity; we often need higher doses and several months to judge full effect; start lower and build; report early side-effects. Not an intoxicating “personality eraser.” Combine with CBT when possible.[1][4]
Surgery. Operations often leave people still distressed or focused on a new area; we recommend treating BDD with therapy and medication rather than chasing a surgical cure.[3]
Partner. Kind reassurance and joint mirror checks can accidentally maintain BDD; we will coach planned support that backs response prevention. [4]
Close. Summarise, teach-back, written information, crisis contacts if mood/suicidality worsens, book review. [4][5]
References
- [1]Phillips KA, Albertini RS, Rasmussen SA A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder Arch Gen Psychiatry, 2002.PMID 11926939
- [2]Wilhelm S, Phillips KA, Didie E, et al. Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial Behav Ther, 2014.PMID 24680228
- [3]Crerand CE, Menard W, Phillips KA Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder Ann Plast Surg, 2010.PMID 20467296
- [4]Castle D, Beilharz F, Phillips KA, et al. Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders Int Clin Psychopharmacol, 2021.PMID 33230025
- [5]Phillips KA, Kelly MM Body Dysmorphic Disorder: Clinical Overview and Relationship to Obsessive-Compulsive Disorder Focus (Am Psychiatr Publ), 2021.PMID 35747292