Is the DSM-5 hoarding disorder diagnosis valid in China?

Hoarding disorder, newly included as a separate diagnostic entity in the Obsessive-Compulsive and Related Disorders section of DSM-5, has been reported to have significantly different symptoms and etiology than obsessive-compulsive disorder (OCD). However, the validity of this new diagnosis in China - where the storing of possessions is sanctioned and normalized - remains to be proven. We considered available data about pathological hoarding in East Asia and found the condition to be relatively common and symptomatically similar to that reported in western countries. We conclude that the 'Hoarding Disorder' diagnosis defined in DSM-5 is a valid clinical entity in China, though when making the diagnosis clinicians must take care to differentiate pathological hoarding that is distressing to the individual and significantly interferes with social and occupational functioning from culturally sanctioned thriftiness that is not associated with either distress or social dysfunction.

Hoarding behavior has long been considered one of the symptoms of obsessive compulsive disorder (OCD). However, recent research reporting significant differences among individuals with pathological hoarding, patients with OCD, and healthy controls in symptomatology, cognitive functioning, family history, and neuro-imaging[ has prompted the American Psychiatric Association to make hoarding disorder a distinct condition in the recently published Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).[ Listed as one of the separate disorders under the new DSM-5 diagnostic group of 'Obsessive-Compulsive and Related Disorders', hoarding disorder has three core symptoms: (a) persistent difficulty discarding possessions regardless of value; (b) the accumulation of possessions congests one's active living space; and (c) hoarding causes clinically significant distress or functional impairment.

Using these criteria, estimates of the prevalence of hoarding disorder in the general population range from 1.4% to 5.8%.[ About 40% of patients who meet diagnostic criteria for OCD have hoarding symptoms (though in most cases it is the not the main OCD symptom), but 80% of individuals with pathological hoarding do not meet the diagnostic criteria of OCD.[ In support of this decision to distinguish hoarding disorder from OCD, a meta-analysis[ found that routine treatment for OCD among OCD patients with hoarding symptoms is significantly less effective than for OCD patients without hoarding symptoms.

However, there is still controversy about whether or not hoarding disorder should be considered an independent diagnosis, particularly in non-western cultures where the storing of possessions, including possessions of little current utility, is sanctioned and normalized. In these settings, direct application of the DSM-5 criteria could lead to over-diagnosis - the medicalization of a culturally acceptable behavior. Most of the research about hoarding has been conducted in high-income countries in Europe and North America, so research in non-western countries and in low- and middle-income countries is needed to assess the crossnational and cross-cultural validity of the new diagnostic criteria for hoarding disorder.

In Japan Matsunage and colleagues[ reported that among 168 patients with OCD, 54 (32%) had hoarding symptoms; consistent with findings from outside of Asia, [ they found that compared to OCD patients without hoarding those with hoarding had an earlier age of onset, more serious OCD symptoms, poorer insight, and a higher prevalence of other comorbid mental disorders. Chasson and colleagues[ assessed the psychometric properties of the Mandarin version of the Obsessive-Compulsive Inventory-Revised (OCI-R) among Chinese OCD patients and found that the internal consistency, test-retest reliability, and criteria validity were all satisfactory and similar to results from other cultural backgrounds.[ In our own recent (as yet unpublished) work, we administered the Chinese version of the Saving Inventory-Revised (SI-R)[ to 341 healthy volunteers and 140 individuals receiving treatment for a variety of mental disorders and found that hoarding was most common in individuals with OCD and, to a somewhat less extent, in individuals with Generalized Anxiety Disorder (GAD). Taken together, these findings suggest, but do not prove, that pathological hoarding is common in East Asia and that the clinical characteristics of the condition are similar to those reported in western countries.

There are, however, some differences between western and Asian results. Factor analysis of the results of a study by Tang and colleagues[ that administered the Chinese SI-R scale to 2100 Chinese university students only identified two independent factors - 'acquisition/difficulty discarding' and 'clutter'; this is different from the three factors identified in Western samples[ ('acquisition', 'difficulty discarding', and 'clutter'). Tang and colleagues[ posit that the reason for the difference may be that in Chinese culture 'acquisition' and 'not discarding' are active and passive aspects of the same traditional cultural concept of 'to save is to earn'. Timpano and colleagues[ compared hoarding behaviors using OCI-R and beliefs about hoarding using a novel hoarding beliefs questionnaire between 303 Chinese and 87 American undergraduates: they found that the mean (sd) overall hoarding score was significantly higher in Chinese students (25.3 [10.7]) than in American students (15.6 [11.6]). They also reported that hoarding behaviors among Chinese students were mainly related to two beliefs ('it could be useful one day' [usefulness], and 'nothing is supposed to be wasted' [wastefulness]), while the American students had a wider range of hoarding behaviors and beliefs (including 'stuff could bring visual joy' [aesthetic qualities], 'stuff can help to invoke specific memories' [remembrance], and 'one has a responsibility to keep stuff in good condition' [responsibility]). Our own (unpublished) work also found relatively high levels of self-reported hoarding behavior in healthy community volunteers. These results suggest that there may need to be some cultural adaptation when applying western-based diagnostic criteria for hoarding disorder in Asian samples and that the cutoff scores for classifying pathological levels of hoarding when using translated versions of western scales of hoarding behavior may need to be revised.

'Making the best use of everything' and 'avoiding waste' are core values in Chinese culture that emerged in times of scarcity when preserving everything that may potentially be of use in the future was a reasonable strategy to enhance personal-security.[ The very high saving rates of personal and family income in China show that these beliefs about personal and family security have persisted despite recent dramatic improvements in living standards. We conclude the 'Hoarding Disorder' is relevant in China, but care needs to be taken to differentiate pathological hoarding that is distressing to the individual and significantly interferes with social and occupational functioning from culturally sanctioned thriftiness that is not associated with either distress or social dysfunction.