Case study: Caucasian female

Instructions:

Read the following case description and then answer the four questions that follow. Type your answers directly into the document. Be as detailed and specific as possible and use examples from the case description to support your answers.

Case Description:

Tina is a 33-year-old, single, Caucasian female who worked for the past several years as a managerial consultant in a consulting firm. She referred herself to an outpatient treatment facility because “My skin is a complete mess … I can’t stop picking it!” During her first visit, Tina told her therapist she picks the skin on her face 7 to 10 times per day in an effort to improve her appearance, unclog pores, or relieve stress. Tina indicated, however, that she sometimes picked her skin “just out of habit.” She picked pimples, marks, blackheads, and dry skin primarily from her face, but would occasionally pick the skin on her chest, shoulders, and back. Most often, Tina used her fingers to squeeze, scratch, and dig at her perceived blemishes. However, sometimes she employed other methods such as pins and tweezers. An average skin-picking episode lasted 30 minutes. Thus, in total, Tina was spending about 3 to 5 hours per day picking her skin.

As part of her job, Tina was frequently called upon to give oral presentations within her company and to her company’s clients. A week prior to her first visit to the treatment clinic, Tina was asked by her boss to provide a keynote presentation at an upcoming business conference. She became extremely “overwhelmed, sad, and anxious” over this request and then engaged in several, prolonged skin-picking episodes. Consequently, Tina called in sick to the office for the remainder of the workweek. For the rest of the week, she stayed inside her house all day to avoid social contact and to prevent others from noticing the impact skin picking had on her face. This latest incident led Tina to become even more concerned about the effects her symptoms might have on her career and social relationships, which thus prompted her to finally seek treatment.

During the initial assessment, it became clear that Tina’s concerns about her work presentations were due to fears that she would be made fun of or rejected if her physical appearance was flawed in any way. Tina spent several hours each day scanning her skin and being preoccupied by any red spots, scabs, bumps, or dry skin she perceived. Despite friends and family who tried to persuade her otherwise, Tina was completely convinced her skin was seriously flawed and ugly. Although her skin was normal (aside from the consequences of her skin picking), Tina tried to camouflage her perceived skin defects with makeup, her hair, and clothing. She frequently checked her appearance by looking in the mirror and by running her hands across her face and body. When these checks led her to perceive a skin imperfection, Tina became preoccupied and distressed, and this would often prompt a skin-picking episode. After a skin-picking episode was over, Tina felt a respite in her distress. However, this relief was short-lived and was immediately followed by feelings of embarrassment, guilt, and heightened anxiety. Moreover, her repeated skin picking had some physical consequences, which included inflammation and bleeding.

Tina was raised in a middle-class family, which consisted of her parents and two older sisters. She noted that two of her immediate family members were treated for psychological disorders while she was growing up. Specifically, her oldest sister had been treated for bulimia nervosa and her father had been treated on different occasions for obsessive-compulsive disorder and major depression. In addition, Tina recalled that her father worried excessively about his weight and was always “yo-yo dieting.” Many of the family activities were focused around exercise and discussions about body shape, weight and appearance

Tina stated that she was a “chubby kid” throughout her childhood and early adolescence. She said she was teased about her weight both at home and at school, which led her to become very concerned about her shape and weight, particularly with regard to her stomach. Because of the teasing, at the age of 15 Tina began to exercise and watch calories, which successfully resulted in weight loss. Tina received considerable praise and positive attention from her family for her weight loss. As a result Tina said that she became less concerned about her body shape and weight (and today she has no concerns about her weight or shape). However, at this time she began to pay attention to other aspects of her physical appearance. Specifically, Tina started to notice and become concerned about perceived red marks and blemishes on her face. Tina told her family about these concerns, and she often asked them to reassure her that her face looked okay. Her family and closest friends repeatedly told Tina that her face looked fine, but no amount of reassurance reduced her discomfort, Tina remained completely convinced that her skin was seriously flawed. Tina became so distressed by her perceived facial blemishes and marks that she began to pick at her skin using her fingers and tweezers in an effort to improve her complexion and to prevent new imperfections from forming.

Her parents tried to help Tina by taking her to the store to purchase products aimed at grooming and hiding her perceived blemishes (e.g., makeup, topical washes and creams). They also sent Tina to a dermatologist when she was 16. The doctor noted that her concern was excessive to any actual skin imperfections (Tina received the same feedback from another dermatologist several years later). None of these efforts were successful and in fact Tina’s symptoms got worse. In addition to her face, Tina began to pick at her chest, shoulders, and back. During the remaining years of high school, she spent more than 1 hour in front of the mirror every morning before class checking, picking, and covering up her perceived skin imperfections. Before bed, she often spent up to 2 hours engaging in these behaviors. Tina was often late to or skipped class altogether because of her skin checking and picking rituals, and because she feared she would be laughed at or rejected by her classmates because of her “disgusting skin.” She became increasingly socially withdrawn, ashamed, disgusted, and depressed.

Tina reported a rather chronic course of her symptoms since they first began at age 15. After high school, she and her second oldest sister moved to another city together, where Tina attended college and subsequently obtained her current employment position. Throughout this time, Tina said her appearance concerns prevented her from engaging in social activities. Tina was interested in an active social and dating life, but she declined frequent invitations to go out from her sister, friends, and colleagues and thus spent most of her time alone. On some weekends, Tina would not leave her apartment at all to avoid running into someone who would trigger her appearance-related anxiety. On the rare occasion when Tina went out with her sister or friends, she found it difficult to enjoy herself. For instance, if Tina was in a restaurant or a nightclub, she would often excuse herself to check her skin in the bathroom mirror. Moreover, she had difficulty engaging in conversations because she was preoccupied with comparing her skin to that of others and by how others might perceive her skin. Although she was an avid musician, Tina’s symptoms prevented her from stage performance due to fears that others would negatively evaluate her because of her skin imperfections. Tina reported two previous romantic relationships (one during college, one in her mid-20s), but stated that her last relationship ended in part because of her resistance enter social situations or leave home.

At the time of her initial treatment contact, Tina was most worried about impact her symptoms had on her work. As a result of her appearance-related rituals, Tina was often late to work and to meetings. Her obsessions about her appearance made it difficult for her to concentrate and stay on task in various work situations. Increasingly, Tina called in sick or cancelled meetings at the last minute because she thought her “skin looked too awful.” She declined any career advancement opportunities that would involve more oral presentations. In sum, Tina now recognized that her appearance-related preoccupations, rituals, and avoidance behaviors prevented her from meeting her goals to further her career, music interests and friendships, and to develop a romantic relationship.

Questions:

1. What is the best diagnosis for the case described above? Include appropriate specifiers (if applicable). [10 points]

2. Provide the DSM 5 criteria for the disorder you have diagnosed the case with and provide a specific and detailed justification/description of how the case meets EACH of the DSM 5 criteria for the disorder (including any relevant specifiers).You may paraphrase or quote from the case description as necessary. [50 points]

3. What factors appear to have contributed to the etiology of the disorder? [10 points]

4. What treatment approach would you recommend for this individual? [10 points]

**Total Deductions (10% each day late) ____________

Total Points Earned (out of 80)____________