Body dysmorphic disorder — structured clinical viva

This is severe BDD with absent/delusional insight, not automatically schizophrenia. Appearance-focused conviction with checking/camouflage and absence of primary thought disorder/hallucinations keeps the formulation in OCRD. Insight is often poorer than in OCD, which traps candidates into antipsychotic-only pathways.[2][5]

Prior treatment was inadequate. Supportive talk without exposures is not CBT-BDD. Brief low-dose SSRIs are not adequate BDD trials (need high-dose SRI for ~12–16 weeks including time at max tolerated dose). First steps: specialist CBT-BDD with ERP-style elements while optimising an SRI such as fluoxetine (RCT evidence including delusional-insight participants).[1][3][5]

Olanzapine demand. Antipsychotics are not first-line monotherapy for core BDD. If later considered for severe agitation, comorbidity, or specialist augmentation contexts, that is secondary to SRI/CBT and requires monitoring — not a substitute for OCRD care.[5]

Surgery letter. Do not collude. Cosmetic procedures have high dissatisfaction and symptom migration in BDD; redirect to psychiatric treatment.[4]

Suicide risk is high in clinical BDD; assess thoroughly and safety-plan regardless of insight argument.[6]