Sunday, August 15, 2010

Doctors debate whether hoarding a real mental illness

If the estimates are true, more than one million Canadians may be living the kind of lives Marie Rose lived, until a two-metre high pile of clothes and clutter collapsed on top of her, suffocating her to death.

It took police and her husband 10 hours to find her body.

The Washington State woman’s tragically bizarre death in 2006 was a severe case of hoarding — a condition that could soon be classified an official mental sickness.

“Hoarding disorder” is being recommended for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, or DSM, an enormously influential catalogue used daily by doctors worldwide that is undergoing its first major revision in nearly 20 years.

Should hoarding make it into the manual, 2% to 5% of the Canadian population could be labelled as having a mental illness, according to studies being used to justify creating the new diagnosis.

Proponents say the goal is to increase public awareness, help identify sufferers and stimulate research and the development of treatments that work.

But critics are uneasy, and question who decides when collecting and saving crosses the line from normal human behaviour to pathological.

“The DSM-5 drafters are having a lot of trouble separating eccentricity from illness,” says Edward Shorter, a social historian of medicine at the University of Toronto and author of A History of Psychiatry: From the Era of the Asylum to the Age of Prozac.

“The real problem is psychiatry’s inability to tell us what really does constitute illness — what is disease in psychiatry? — because there are so few objective standards, unlike any other field of medicine,” Mr. Shorter says.

“In psychiatry, the rule of thumb is: If you think you’re sick and I think you’re sick, then you’re sick.”

Under the proposed diagnosed criteria, hoarding is defined as “persistent difficulty discarding or parting with possessions,” regardless of their worth. (Animals aren’t specifically mentioned, but the working group is considering adding them to the proposed criteria. In July, 44 dogs were seized from a feces-covered garage in Gull Lake, Man., owned by a couple that, according to a Winnipeg Free Press report, described themselves as Good Samaritans trying to save the animals from those who had abandoned them.)

Hoarders accumulate stacks of worthless objects that can make homes fire traps and entire rooms unlivable. They hold on to them for comfort, sentimental attachment (many cases start after the death of a loved one) or out of a firm belief that they may come in handy some day.

Hoarders hoard newspapers, magazines, empty food packages, pizza boxes, clothes, Kleenex, plastic bags, car parts, electronic equipment, tools, furniture and — particularly for women — wool, fabric and craft supplies. It starts somewhere — the back of the car, the backyard or the garage — “and it spreads from there,” says Elaine Birchall, an Ottawa social worker who counsels hoarders. Other “life forms” move in, she says — cockroaches, silver fish, mice.

Ms. Birchall was recently involved in a voluntary “clean” where 11 tons of material were removed from a three-bedroom bungalow in Ottawa. There were cans of food dating back to the 1980s.

Hoarding affects all socioeconomic groups and, while those who seek help are overwhelmingly female, some studies suggest men are more affected than women. People become socially isolated.

“They’re ashamed of having people over, it interferes with their relationships with relatives; neighbours might start complaining — it kind of snowballs,” says David Mataix-Cols, an advisor to the working group recommending hoarding be added to the DSM.

The disorder isn’t listed in the current edition, except as one of the criteria for obsessive-compulsive disorder, or OCD.

But the drugs and behaviour therapy used for OCD barely touch hoarders, if at all, researchers say. Nor do hoarders experience intrusive thoughts, images or impulses, says Mr. Mataix-Cols, a senior lecturer in the Institute of Psychiatry at King’s College London.

“They’re not constantly bombarded with unpleasant thoughts about their possessions at all.

“If we call them OCD, and we keep giving them some treatments and we keep failing, we’re not going to get very far.”

He says the idea isn’t to pathologize normal human behaviour.

“Many people have asked, how do we separate the stamp collector who’s a bit eccentric and has millions of stamps” from a pathological hoarder, he says.

The healthy collector, says Mr. Mataix-Cols, “doesn’t feel any distress whatsoever and there’s no interference with everyday life.”

He says the provisional diagnostic criteria are conservative and worded in such a way that only those suffering true distress and impairment would get a hoarding diagnosis.

Dr. Frank Farley isn’t so convinced.

“Don’t do it,” says the Edmonton native and former president of the American Psychological Association.

“The diagnostic bible just gets bigger and bigger. Where’s it headed?” he says.

The current edition lists 357 psychiatric afflictions, up from 128 when the first slim volume was published in 1952.

“Treat hoarding in some other category, rather than creating yet another one that may or may not be valid and extensive enough to have a new category for,” says Dr. Farley.

He says the quoted prevalence rates “need to be taken with a grain of salt. Nobody is testing the whole country. They’re projections based on small samples. “

“You don’t want to create a whole sort of science on a few unusual cases,” says Dr. Farley.

“The drug companies will start creating drugs allegedly specifically for ‘hoarding disorder’ and away we go, we’re off to the races one more time.”

http://www.nationalpost.com/news/Doctors+debate+whether+hoarding+real+mental+illness/3401981/story.html