Nature Medicine | Spoonful of Medicine

Get your house in order

This article in the newspaper El Mundo, which reports on a paper published in 2008 in the American Journal or Psychiatry, definitely caught my imagination.

The authors of the paper in question, entitled “Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both?” studied a group of people with the strong drive to gather stuff to the point of making their houses uninhabitable, as exemplified by the picture below, credited to Boston University and published in El Mundo.

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Does this look familiar to you?

The question they asked was whether compulsive hoarding is a disease in its own right or a symptom of obsessive-compulsive disorder (OCD). The conclusion was that it is a disease in and of itself, and that “These findings have implications for the classification of OCD and compulsive hoarding in the next edition of DSM”, perhaps getting its own entry in the legendary diagnostic manual.

I don’t mean to criticize these authors’ research, which, in fact, builds on an extensive literature on compulsive hoarding. I nevertheless find it somewhat disappointing that psychiatry carries on having this distinct fascination with taxonomy, which, regardless of its diagnostic use and validity, does very little to help us understand the underlying biology of disease and come up with new therapeutic approaches to treat the disorders of the mind.

In other words, is it realistic to think that we’ll help people who hoard compulsively (assuming that we buy into the idea that this is really a disease, something that I’m not sure everyone will subscribe to) by categorizing their condition separately from OCD? Is it really a big advance to say to a patient “You don’t have OCD; you only have compulsive hoarding”? It may provide comfort to some patients but, at the end of the day, I’d argue that it makes little difference.

What I’m trying to say is that, at a time in which the concept of endophenotypes is beginning to gain traction as a new way to parcel psychiatric diseases, it would be a shame if we don’t seize the opportunity to start thinking about endophenotypes as features of a mental disease that have a specific, experimentally approachable biological foundation, instead of coming up with endophenotypes that are as unapproachable as the original disease or, even worse, coming up with new diseases altogether.

As for the DSM-IV, I get the feeling that it has come to the end of its useful life. Work is underway on the DSM-V, publication of which is scheduled for May 2012. Although it would be nice to think that the new edition will represent a break from the past, pushing the current boundaries of the discipline, I’m not so optimistic about it. Instead, I strongly suspect that we will see a much larger, encyclopedic book, with extensive discussion about many more conditions and diagnoses, many of which would be quite esoteric — a lot of heat, but very little light. So, even though the field of psychiatry is in more dire need to get its house in order than some of those compulsive hoarders, I don’t see it happening between now and 2012.

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    Alan Dove said:

    The biggest obstacle to a radical revision of the DSM is bureaucratic rather than scientific. The DSM-IV has been welded into the policies of Medicare, Medicaid, and every private insurer in the US, as well as many of the government agencies that pay for healthcare in other countries. Psychiatrists can’t bill for treatment without applying an appropriate DSM-derived code to the patient’s condition. Reframing the diagnostic criteria in terms of endophenotypes and neurochemistry makes great sense scientifically, but it will meet enormous resistance from the bean-counters.

    COMMENT FROM JCL:

    I entirely agree with your assessment, except that I think that both scientific and bureaucratic obstacles get on the way of modernizing the DSM-IV. Also, Marcia Angell recently wrote in the New York Review of Books an article in which she made reference to the conflict of interests that many of the people in charge of revising the DSM-IV have. This add another layer of complexity to the whole revision.