When it comes to mental health disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM, in this case the DSM-5) is an important part of diagnosing for medical professionals. We especially talk a lot about it in the BFRB community because of the recent addition of dermatillomania (listed as Excoriation (Skin Picking) Disorder) and because of the re-categorization of all BFRBs. Formerly a part of the Impulse Control Disorder section, trichotillomania, dermatillomania and all BFRBs are now nestled in among Obsessive-Compulsive and Related Disorders. And while that’s all fine and dandy, I couldn’t help but wonder exactly what the DSM-5 says about these disorders specifically and in a broader sense as a part of the OCD spectrum. So I bought my own copy of the DSM-5 (on sale!) to find out.
Firstly, here is the list of what falls into this category: obsessive-compulsive disorder, body dysmorphic disorder, hoarding, trichotillomania, excoriation (skin picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, obsessive-compulsive and related disorder due to another medical condition, other specified obsessive-compulsive and related disorder, and unspecified obsessive-compulsive and related disorder.
That’s a pretty big list and it’s a wonder BFRBs fit in there at all. However, the DSM-5 doesn’t try to lump it in as being the exact same as what people typically think of obsessive compulsive disorders.
It acknowledges BFRBs as unique when it says, “Other obsessive-compulsive and related disorders are characterized primarily by recurrent body-focused repetitive behaviors (e.g., hair pulling, skin picking) and repeated attempts to decrease or stop the behaviors.” While other obsessive-compulsive behaviors can have a bodily component, like hand washing, the DSM-5 recognizes that those behaviours are not stemming for a focus on the body and have other factors that incite the behaviour. Specifically mentioning BFRBs sets trichotillomania, dermatillomania and other behaviours like those apart from traditional OCD.
The DSM-5 even states that “there are important differences in diagnostic validators and treatment approaches across these disorders,” which I feel was definitely important for the editors to include because while BFRBs are officially under the OCD spectrum, they don’t necessarily work the same way and thus won’t react the same to treatments.
One of the criticisms of having dermatillomania and other BFRBs added to the DSM-5 was that it was just making common behaviours into a problem. And for those that worry along the same lines about these disorders being over-diagnosed or having a diagnosis for them placed on people who participate in normal grooming behaviours—a.k.a. the casual pull of a stray hair or pop of a pimple—the DSM-5 covers that in the introduction to OCD and related disorders as well.
“The obsessive-compulsive and related disorders differ from developmentally normative preoccupations and rituals by being excessive or persisting beyond developmentally normative periods.”
Summing that up, it says, yes, people pull and pick, but this goes way beyond that. This goes beyond “normal” (and I place normal in quotation marks because normal is subjective and labelling someone or something as abnormal can be damaging). It also goes on to talk about how skin picking and hair pulling have negative effects on a person’s life and causes impairment or difficulty in everyday functioning. This isn’t casual and then it’s over and done with; it’s prolonged and distressing to those who do it. This isn’t making a disorder out of nothing; this is a legitimate problem people face.
The DSM-5 briefly summarizes trichotillomania and dermatillomania in this introduction, but more details come from the specific sections on these disorders.
What the DSM-5 Says About: