Obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) often co-occur, creating complex symptom profiles and requiring multifaceted treatment approaches. OCD can lead to intense self-monitoring and distressing obsessive-compulsive behaviours, while BDD contributes to a distorted self-image, exacerbating feelings of inadequacy and shame. This case study explores the use of a metacognitive approach using Dramatised Socratic Dialogue (DSD) in the treatment of a patient with severe OCD and BDD, focusing on relational challenges, pervasive shame and self-criticism.

To evaluate the effectiveness of dramatised Socratic dialogue and exposure with response prevention (E/RP) in the treatment of a complex case of OCD and BDD. Specifically, to address intrusive self-criticism, enhance the therapeutic alliance, and reduce shame-related behaviours.

A 33-year-old man with a long history of OCD and BDD symptoms, including excessive mirror checking and social avoidance, was assessed using the MMPI-2, PID-5, MADRS, STAY-1 and 2, and Y-BOCS, confirming OCD, BDD, and major depressive disorder. Treatment included establishing a strong therapeutic alliance, psicoeducation, E/RP and DSD targeting persistent self-criticism. After an initial phase, interventions focused on reducing compulsive behaviours and promoting self-acceptance.

Initial E/RP led to symptom improvement but maintained a sense of control that limited full therapeutic progress. DSD successfully reduced self-critical dialogue and addressed shame and self-perceived social unacceptability, although it temporarily disrupted the therapeutic alliance. Subsequent reintegration of E/RP alongside DSD facilitated substantial reductions in OCD and BDD symptoms, with the patient reporting increased mood stability and reduced social avoidance.

This case highlights the benefits of integrating dramatised Socratic dialogue with traditional CBT methods such as E/RP to address OCD and BDD symptoms where shame and self-criticism are significant. DSD proved effective in reframing negative self-talk, breaking cycles of self-criticism and supporting long-term symptom reduction. This approach shows promise for treating complex cases involving intense feelings of inadequacy and shame.

None Declared