In the run-up to the publication of DSM-5, when mountains of press reports described the manual’s revised content, most of the attention understandably went to the APA’s more-controversial changes. Those included the decision to delete the so-called Bereavement Exclusion Clause, allowing Major Depression to be diagnosed among those still grieving intensely after 14 days. Much less attention was given to Hoarding Disorder, which seemed to be accepted with relatively little doubt or fuss—perhaps because of the widespread popularity of the A&E series Hoarders, perhaps also because Americans, encouraged to be avid consumers, at some point must contend with the related problem of clutter—of having too much stuff.
DSM-5 characterizes Hoarding Disorder as “persistent difficulty discarding or parting with possessions, regardless of their actual value.” Sound familiar? The afflicted insist on “a perceived need to save the items” and experience “distress associated with discarding them.” The result is an “accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use.”
The APA can't have been watching much HGTV lately, with its hourly devotion to afflicted couples and families struggling over whether to stay-but-renovate or expand into an often much-larger home. But one needn’t fall into the trap of confusing hoarding with collecting or passive accumulation to recognize that there are serious problems with the way the new condition is defined, making overdiagnosis a likely outcome. For starters, large numbers of Americans will recognize themselves in the phrase “persistent difficulty discarding or parting with possessions,” not least because the latter don’t need to have “actual value” for us to experience distress in parting with them. Additionally, with 30 percent of all British men self-identifying as collectors, what counts as clutter or appropriate/reasonable “object accumulation,” including personal memorabilia, is “a line carved in sand,” as Gary Greenberg puts it in The Book of Woe, in a particularly excruciating account of how the APA devised and approved the new disorder.
Given how sanguine the media have been about that approval, it was pleasing to see a cogent, stimulating review of Greenberg’s book take issue with this development, and by a psychiatrist himself citing decades of experience. In the July issue of Tikkun Magazine, Phil Wolfson asks: “Is there really such a thing as a hoarding ‘disorder’?” Certainly, “there are humans who hoard, shutting themselves into narrow confines in their homes between piles and extraordinary collections of useless things that they consider their sacred, un-eliminable possessions. Their lives are often tortured, depressed, fearful, and isolated. Their relatives feel helpless and confused. They don’t seek treatment and if it is imposed, do very badly in terms of cleaning up their act. This is certainly a difficult and annoying thing. Not to be minimized as suffering. But an illness? Hardly. It has deep and complex roots to be sure. But it’s one of an infinite variety of strange behaviors of which most of us are capable at some time.”
“To be honest,” he adds, in a personal aside that helps expose the wavy line joining obsessive collecting to hoarding and simple accretion, “I myself am a bibliophile. I hate throwing out my books. They are important to me, like friends that give me a sense of security, of times past, and of ideas and fantasies that I used to have.… It creates in me a bit of distress when I have to find more room for them. And for my mate, she may feel their presence and their Andromeda spread and have feelings. It’s not enough to reach the DSM-5 criteria to give me a hoarding disorder diagnosis, but it’s a symptom for sure.”
Wolfson’s anecdote nails a symptom of “persistent”—possibly “unreasonable”—attachment to objects that are difficult to discard, generally because of their real or perceived value; they definitely can cause clutter, can grow bothersome to self and companions, and even increase risks as a fire hazard. Wolfson’s behavior checks all of the boxes in the DSM criteria (including, for some, impairment), yet for most of us it nonetheless remains squarely in the realm of standard, even obligatory, professional behavior.
In a 2010 article seeking to differentiate such behaviors but ultimately revealing how close they often come, psychiatrist David Mataix-Cols and his colleagues usefully conceded: “It is unclear if hoarding is as much of a problem in developing countries as it is in industrialized ones, in individualistic versus collectivistic cultures, and in urban versus rural communities (where space may be less of an issue). Research on different ethnic groups within Western societies is also lacking.” But with its single-minded (obsessive?) focus on biomarkers and open conjecture that “hoarding disorder may have unique neurobiological correlates” (April 13, 2013 Highlights of Changes from DSM-IV), the APA is turning much-needed attention from such necessary cultural and environmental factors, more or less limiting focus to the brain and its seeming disorders. Yet hoarding is widely acknowledged to stem from a spectrum of factors, from compulsivity and unacknowledged trauma, to professional necessity and those who can’t let go of material because of its sentimental or seeming creative value.
It’s the very elasticity of the APA’s new psychiatric condition that heightens the risk that all such behaviors will end up receiving the same label—that the disorder will be widely misapplied. In failing to note that looseness of language, media reports unwittingly have stamped their own approval on how the APA believes we should now treat “accumulated objects.” How to organize our pasts—including how much of that history we should try to retain through attachment to objects—remains an active, ongoing question.
Wolfson’s review of The Book of Woe appears here.