Rachel Cooper on classifying mental disorders and the DSM

Do you have a mental disorder? In many contexts, it depends on whether your behaviour meets any of the sets of diagnostic criteria included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a classification of mental disorders, published by the American Psychiatric Association, but used worldwide.

In May 2013, a new edition of the DSM (DSM-5) was published, and the domain of mental disorder shifted. Here I will focus on one newly included disorder, hoarding disorder—a diagnosis for people who compulsively hoard junk. Through considering hoarding, I will show how the question of which conditions should be included in the DSM depends not only on empirical facts, but also on conceptual and ethical questions.

Revising the DSM is a huge undertaking that involves many experts working for years. The committees responsible published papers justifying the revisions that they made. In making a case for hoarding to be included in the DSM, three hurdles had to be cleared—scientific, conceptual, and ethical.

First, the scientific hurdle: The committee asked whether hoarding could be considered a distinct condition. In particular, it weighed the evidence that hoarding can properly be considered a distinct condition from obsessive-compulsive disorder (OCD). A number of studies suggested key differences between hoarding and OCD. Patients experience the two conditions differently: while obsessive thoughts are typically experienced as intrusive, thoughts associated with hoarding normally fit coherently with a patient’s other thoughts and values. There seem to be differences in natural history: while hoarding typically gets worse over a life-time, OCD does not. Neuroimaging studies suggest distinctions between hoarders and those with OCD. Treatment response may differ in that people with OCD tend to be more responsive to certain drug therapies. Taken together, there seems fair evidence that hoarding and OCD are distinct.

The paper then tackles the second, conceptual, hurdle—does hoarding fit the definition of disorder? The definition of mental disorder followed by the DSM requires that

[…] each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with significantly increased risk of suffering death, pain, disability, or an important loss of freedom […] Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above.

The review paper goes through the DSM definition point by point to see if hoarding can be made to fit. The issues of distress or impairment, and of clashes of values, are especially problematic. Many hoarders deny that they have a problem; they may not see their hoard as junk, but as stuff that they will one day use. Faced with such difficulties, the review authors decide to interpret ‘distress or impairment’ liberally. They conclude that the criterion is met as hoarding can pose a health hazard and lead to conflicts with others. The reviewers see the conflict between hoarder and society as being rooted in a problem in the hoarder: ‘given the evidence of associated impairment and underlying disturbance, it seems clear that compulsive hoarding is not solely a result of social deviance or conflicts with society’.

The final hurdle that hoarding had to clear before being included in the DSM was ethical. Guidelines for those revising the DSM demanded that proposers should consider whether ‘the harm that arises from the adoption of the proposed diagnosis exceed[s] the benefit that would accrue to affected individuals’. Only revisions that on balance do no harm were to be accepted. The reviewers briefly discuss the potential harms and benefits of including hoarding disorder in the DSM. They conclude that on balance the new diagnosis can be helpful in that it will ‘likely increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder’.

I have a number of interconnected concerns about the inclusion of hoarding disorder. First, let’s remember that patterns of consumption and waste disposal have varied radically across place and time, and differ between individuals. Susan Strasser’s (1999) Waste and Want: A Social History of Trash shows that there is nothing that is unambiguously rubbish. Whether someone is ‘hoarding junk’ is not a straightforwardly factual matter as ‘what is rubbish to some is useful or valuable to others’. Strasser’s work also makes it clear that twenty-first-century-style hoarding can occur only within a very particular cultural niche. We live in cultures of plenty and consumption, where it is common for much to be thrown away. In contrast, throughout history and in most places, most people have had little and wasted less.

Still, although rubbish may be relative, and although hoarding has not always been possible, shouldn’t we admit that those who fill their houses from floor to ceiling with precarious piles of newspapers and boxes have a mental health problem? I accept that the relationship between hoarder and possessions is unusual, and also think that it is unwise to fill one’s house with junk, but I am still not entirely convinced that hoarding is best thought of as a mental disorder. Remember, first, that there are many habits and behaviours that are unwise but that we do not pathologize. For example, many of us reduce our life expectancy by years because we fail to exercise or to eat healthily. Others fail to back-up computer files, or to save adequately for old age. Maybe hoarding differs from such examples of folly in that hoarding is more unusual, but rarity in itself cannot transform a pattern of behaviour from a bad habit into a disorder.

Those who consider hoarding a disorder will likely point out that hoarding disorder is associated with distinctive patterns of brain activity, and can be further distinguished from ‘normal behaviour’ by its natural history, treatment response, and the way in which it seems to run in families. But we should note that none of these natural facts can clearly distinguish a disorder from a normal (though in this case unwise) pattern of behaviour. Normal behaviours, for example playing music, may also be accompanied by distinctive patterns of brain activity, can be affected by psychoactive drugs, have a distinctive natural history, and run in families.

Whether hoarding should be considered a disorder must depend also on whether we consider it to be the sort of problem that is appropriately dealt with by medical means, and here we should pause. Medical treatment implicitly takes the root cause of a problem to be located ‘within’ an individual, but problematic hoarding arises only in certain environments. Consider that one key factor distinguishing those who meet the diagnostic criteria for hoarding disorder from sub-threshold cases is that those who fail to meet the criteria ‘were more likely to live in larger properties that had, on average, an additional room’.  Here we see that hoarding problems arise relationally—the combination of individual characteristics, living situation, and broader material and social environment, results in problems. It is plausibly the case that if hoarders were psychologically different, they wouldn’t hoard. But equally, if they had bigger houses, there wouldn’t be a hoarding problem either.

We should also worry about the fact that hoarders are said to often ‘lack insight’—that is, they don’t think they have a problem, and they don’t want to be helped. Remember that new disorders are supposed to be added to the DSM only if they are likely to do more good than harm. The addition of hoarding disorder to the DSM will facilitate the diagnosis and treatment of those who do not want to be diagnosed or treated. It is worth reminding ourselves that treating those who ‘lack insight’ is generally a nasty business, and frequently involves tears and arguments. I am not suggesting that all hoarders should be left alone. Certainly, it is true that sometimes an individual’s possessions will need reining in by others. A vermin ridden or structurally unsound house must be dealt with. But there are already laws for dealing with such problems. My worry is that in medicalizing hoarding, the threshold for coercive intervention will become much lower. The risk is that rather than intervention being thought justified only when the welfare of others is at risk, ‘help’ will be provided in much less severe cases for the hoarders ‘own good’.

It is easy to criticize, harder to make positive suggestions. If I think including hoarding disorder as a new category in the DSM was a mistake, what would I have recommended instead? At present, forms of cognitive behavioural therapy are amongst the most promising treatments being developed for hoarding. For example, with colleagues, Randy Frost has developed a self-help support group programme called the Buried in Treasures workshop. Hoarders meet with other hoarders, discuss a chapter from the accompanying book, and complete weekly exercises dealing with acquisition, discarding, and disorganization. Initial trials suggest the therapy is highly effective. If Frost’s programme works, then this is great news. But there is no need to think of this as ‘therapy’; it could equally be framed as a structured and peer-supported programme for dealing with a bad habit (rather like Weight Watchers). There is often no need to pathologize hoarding for hoarders to be helped.

Finally, I should emphasize that although I think hoarding might often be better considered a bad habit than a disorder, I do not think that this also applies across the board to other diagnoses added to the DSM. Each condition added to the DSM is unique, and must be considered afresh.

Rachel Cooper is Senior Lecturer in Philosophy at Lancaster University. This essay has been extracted and adapted from her Diagnosing the Diagnostic and Statistical Manual of Mental Disorders  (Karnac Books, 2014), and is reprinted with kind permission of Karnac Books. Her research interests include the philosophy of science and medicine, and particularly the philosophy of psychiatry.