TPC-Journal-V4-Issue3

The Professional Counselor \Volume 4, Issue 3 212 Comorbid Diagnostic Formulation Comorbidity refers to the presence of multiple diagnoses or pathologies within the same individual (Jones, 2012). This final section presents a discussion on the DSM-5 ’s new obsessive-compulsive and related disorder, excoriation (skin-picking) disorder and the revised conceptualization of post-traumatic stress disorder. Excoriation (Skin-Picking) Disorder Excoriation, also referred to as dermatillomania (Grant et al., 2012), is characterized by the repetitive and compulsive picking of skin, leading to tissue damage, and is a new diagnosis to the DSM-5 . This addition reflects the growing prevalence of this psychiatric condition (Grant et. al., 2012). Excoriation is characterized by compulsive picking, rubbing, squeezing, lancing or biting of the skin. Not included in this disorder are individual behaviors that involve nail biting, lip biting or cheek biting. If individuals manifest these conditions they are coded as other specified obsessive-compulsive related disorder (APA, 2013, p. 263). Cutting, or nonsuicidal self-injury, is not a codable mental disorder in the DSM-5 (see APA, 2013, pp. 803–806) and is not conceptualized in the symptomology of excoriation. Counselors are encouraged to consider cutting behavior in their clients as manifestations of symptoms related to depressive disorders, bipolar disorders, anxiety disorders, trauma disorders—and most particularly dissociative identity disorder and borderline personality disorder, in which self-injurious behavior is frequent. Individuals engaged in excoriation may target their face, arms, hand, skin irregularities, pimples, calluses or scabs. They may use objects such as tweezers, pins, scissors and fingernails and be triggered by anxiety, boredom, distress or tension (Grant et al., 2012). Some individuals with excoriation display rituals (e.g., biting off, chewing and swallowing skin), permanent skin damage, scarring, lesions, infection or disfigurement. Individuals with excoriation spend several hours per day for months and years picking at their skin, thinking about picking, and resisting urges to pick. Because the skin-picking is so frequent, pain is not routinely reported. Marked functional impairment from excoriation may include work interference, missed school, difficulty managing school tasks and studying, and avoidance of social or entertainment events. Excoriation cannot be due to physiological effects of a substance (e.g., methamphetamine or cocaine), to another medical condition (e.g., scabies), or better explained by symptoms of another disorder (APA, 2013). Post-Traumatic Stress Disorder Some important modifications to post-traumatic stress disorder occur in the DSM-5 . First, the DSM-IV-TR language has shifted from “threat to the physical integrity of self or others” (APA, 2000, p. 467) to “sexual violence” (APA, 2013, p. 271). Second, the DSM-5 removed the DSM-IV-TR criterion A2 “subjective fear-based distress” because not all traumatized individuals experience fear, terror or horror when exposed to a trauma stressor. Some traumatized individuals may become anhedonic, dysphoric, aggressive or phobic; experience arousal and reactive-externalizing behaviors; or experience dissociation. Third, a new trauma exposure source is added to the traditional DSM-IV-TR trauma sources (i.e., directly experiencing, witnessing, and learning that a traumatic event occurred to a close family member or friend): “experiencing repeated or extreme exposure to aversive details of the traumatic event(s)” (APA, 2013, p. 271). An important note regarding this new exposure source in the DSM-5 indicates that “criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless exposure is work related” (APA, 2013, p. 271). Examples of work-related electronic media exposure may include an individual who edits graphic news video or pictures, an individual who performs frequent digital-based forensic science investigations of graphic crime scenes, or an individual who views military-oriented electronic images displaying graphic human remains captured from unmanned aerial vehicles. Fourth, the DSM-5 requires that an individual manifest at least one symptom from each of the following pathological clusters: