A modest proposal regarding DSM 5

by Seán Ó Tarpaigh

As therapists we tend to treat the DSM (2013), and diagnosis generally, with a degree of caution, if not downright scepticism. The origins, history, and methodology of the DSM all give rise to serious questions about its efficacy and application in many of our therapeutic settings. Concerns are not confined to the psychotherapy profession but can also be found among the psychiatric community and literature (Frances, 2013; Baca-Garcia et al., 2007).

Amongst the concerns often raised regarding the DSM methodology are, for example, the dangers of cultural biases, and labelling (Honos-Webb & Leitner, 2001). Also much discussed are conflicts of interests amongst the authors of the DSM (Greenberg, 2012). Researchers Cosgrove and Krimsky (2012) found that 69% of the DSM-5 task force members report having ties to the pharmaceutical industry. A particular concern for therapists is that of over-diagnosis or the pathologising of natural responses to the everyday challenges of life (Frances, 2010). This latter point is particularly evident in the latest addition which includes a diagnosis of “Prolonged Grief Disorder” in the DSM 5-TR (2022, pp. 322-27). This appears to pathologise grief if, after just one year the sufferer displays “intense yearning” for, and “preoccupation” with the deceased (p. 324). Our own response and those of our clients might lead us to question the usefulness of this kind of diagnosis. One year seems oddly arbitrary, if not meaningless, to anyone who has lost a loved one. Grief is complex and unique to each individual and circumstance. Death is permanent and can, among other things, upend our sense of time and our sense of security and stability. Intense yearning and/or preoccupation may very reasonably continue for an extended even indefinite period if, for instance the bereaved is elderly, or the deceased is a child, or has been a victim of violence. However, this pathologising may make more sense when seen in an American context, where, amongst other considerations, the pressure to diagnose equals insurance cover equals sales of medications equals profits for insurance providers, physicians, and pharmaceutical companies. One does not have to be overly cynical to imagine that such a system of interconnections could, at least in part, lead to over-diagnosis.

Having said all this it may come as a surprise that I wish here to suggest yet another addition to the latest DSM edition. It seems to me a glaring omission that if we are to label “prolonged grief” as a psychiatric disorder, there is surely a place for many other human emotions and behaviours which could merit inclusion. Take for example that most pernicious human behaviour which we know as greed - prolonged greed, obscene greed, insane greed, most especially in the teeth of the present-day existential threat of climate collapse. If one were to watch an individual atop a giant sequoia tree, sawing happily at the supporting branch, without regard to their safety or very survival, we would surely think such an individual merited inclusion in any diagnostic of mental disorders.

I humbly present, therefore, my modest proposal for the inclusion of what I will refer to as CAD, Compulsive Acquisition Disorder® (aka Easter Island Syndrome) as would be formatted in the DSM:

Compulsive Acquisition Disorder (CAD)
CAD is a mental disorder characterised by persistent and excessive acquisition of possessions and/ or money regardless of need. The individual experiences an intense urge or desire to acquire ever more cash, goods, property, status, power, or experiences. This is done regardless of consequences to others or society in general. There is no point of satiety.

Diagnostic criteria
A. Recurrent and persistent, excessive acquisition of possessions, money, and property etc. beyond what is reasonable.

B. The excessive acquisition is continued regardless of consequences to others and is often achieved by questionable and risky practices.

C. The symptoms cause clinically significant impairment in social, romantic, familial, and occupational relationships. The primary attachment is not to people but to possessions, money and/or status.

D. The symptoms are not better explained by another mental disorder (e.g. hoarding disorder, obsessive-compulsive disorder).

Specifiers
Specify if:

• With good insight
• With poor insight
• With absent insight/delusional beliefs
• With focus on status and power
• With reclusive or secretive tendencies

Specify if:

• Episodic: Symptoms present for less than 1 year
• Persistent: Symptoms present for 1 year or more

Diagnostic Features
Individuals with CAD experience a persistent, irresistible urge to acquire possessions, power, money, debt, without any thought given to the actual needs of the individual or consequences to others. The acquisition of items can be through multiple means such as buying, trading, deceit, or obtaining for free. The items, money or assets acquired sometimes result in the accumulation and manipulation of debt and the resulting stress can dominate daily activities, relationships, and functioning. Individuals with CAD may experience no feelings of distress or shame about their behaviour or its consequences to others, yet they feel righteous and entitled to continue to accumulate. They may attempt to hide their behaviour from themselves and others with tokens of charitable activities which may often profit them in extraneous ways, particularly outward status. They will often involve themselves in power structures, especially the political system which they will manipulate for their personal aggrandisement and power.

Prevalence
CAD is an increasingly common disorder in the more privileged echelons of society.

Studies suggest that it affects around 1% of the general population but exceeds 90% of the hyper- affluent, powerful, and non-domiciled cohort of the population. It is important to note that CAD occurs along a spectrum and that most of the population may have some degree of CAD which can also have adverse effects at various points along this spectrum.

Development and Course
CAD typically begins in adolescence, with symptoms persisting into adulthood. The disorder generally worsens over time, with an increasing accumulation of possessions, money, assets and/or debt, along with ever more illicit dealings and activities. This usually leads to greater interference with daily life and relationships.

Specify if:

• Inherited

• Self-generated

Comorbidities
CAD often has comorbidity with personality disorders especially Cluster B (Narcissistic, Histrionic, and Antisocial) disorders and with OCD personality disorder (Cluster C).

Differential Diagnosis
CAD needs to be differentiated from other mental disorders that may present with similar symptoms, such as:

• Hoarding Disorder

• Obsessive-Compulsive Disorder

• Substance Use Disorders

• Addiction Disorders

Treatment
CAD is very resistant to treatment. The sufferer is often unaware, in denial, or delusional regarding there being an issue at all and will be very dismissive of the very idea of therapeutic intervention. Typically, there is a strong sense of entitlement and lack of shame or morality. Relational therapies are dismissed as they are seen as a threat to defences against deeper insecurities which lie at the heart of the disorder. This also happens with somatic approaches. Cognitive-behavioural therapy focuses on developing strategies to resist urges to acquire yet more possessions, money, status etc. CBT may help by heightening awareness of the consequences of such behaviour. Treatment may involve medication, such as anti-depressants, to reduce impulsivity. Family therapy may be useful in improving social support and by increasing awareness of others impacted by the compulsive acquisition behaviour, thus breaking through the delusional bulwark of the sufferer to reveal the often-catastrophic consequences of the behaviour to family and society.

Conclusion
I am sure we can all think of well-known individuals and groups (cads!) throughout the world who qualify for a CAD diagnosis: billionaire royals who hide their wealth and use their influence to avoid taxes (Evans & Pegg, 2021); billionaire owners of pharmaceutical companies happy to make ever more profits on the back of utter misery for thousands of vulnerable individuals (Keefe, 2021); oligarchs and political leaders heedlessly destroying irreparable natural environments to hoard even more billions in a society and ecosystem collapsing under the weight of greed, or compulsive acquisition. All of these and more will not, at present, find a DSM diagnosis. This is a particular disorder that urgently requires recognition, for how can we offer a treatment if we haven’t even given it a name and a nosology?

I will leave the last word to Shakespeare, who as so often was ahead of the curve with a diagnosis of unrestrained greed, its development, and its consequences which I hereby term Compulsive Acquisition Disorder, CAD. ®

Then everything includes itself in power,
Power into will, will into appetite;
And appetite, a universal wolf,
(So doubly seconded with will and power),
Must make perforce a universal prey,
And last eat up himself.

Shakespeare (1997) Troilus and Cressida I iii 119-124

Seán Ó Tarpaigh MSc is a Gestalt psychotherapist and graduate of the Metanoia Institute, London. He has trained in EMDR, Internal Family Systems and practices mindfulness-based approaches. Having worked in London’s Priory Hospital, he now has a private practice in Monkstown, Dublin. He previously worked as a professional actor and director and Irish language translator.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Baca-Garcia, E., Perez-Rodriguez, M.M., Basurte-Villamor, I., Fernandez del Moral, A.L., Jimenez- Arriero, M.A., Gonzalez de Rivera, J.L, Siaz-Ruiz, J., and Oquendo, M.A. (2007). Diagnostic stability of psychiatric disorders in clinical practice. The British Journal of Psychiatry. 190 (3): 210–216. doi: 10.1192/bjp.bp.106.024026.

Cosgrove, L. & Krimsky, S. (2012). A comparison of DSM-IV and DSM-5 panel members’ financial associations with industry: A pernicious problem persists. PLoS Med, 9(3): e1001190. https:// doi.org/10.1371/journal.pmed.1001190

Evans, R. & Pegg, D. (2021, February 7) Revealed: Queen lobbied for change in law to hide her private wealth. The Guardian. https://www.theguardian.com/uk-news/2021/feb/07/revealed- queen-lobbied-for-change-in-law-to-hide-her-private-wealth

Frances, A.J. (2010, June 2). Psychiatric Fads and Overdiagnosis. Psychology Today. https:// www.psychologytoday.com/us/blog/dsm5-in-distress/201006/psychiatric-fads-and- overdiagnosis https://en.wikipedia.org/wiki/Allen_Frances

Frances, A. (2013, August 13). The New Crisis in Confidence in Psychiatric Diagnosis. Annals of Internal Medicine. https://doi.org/10.7326/0003-4819-159-3-201308060-00655

Greenberg. G. (2012, January 12). The D.S.M.’s Troubled Revision. The New York Times. https://www. nytimes.com/2012/01/30/opinion/the-dsms-troubled-revision.html

Honos-Webb, H. & Leitner, L.M. (2001). How Using the DSM Causes Damage: A Client’s Report. Journal of Humanistic Psychology, 41 (4): 36–56. https://doi.org/10.1177/00221678014140

Keefe, P. R. (2021) Empire of Pain. Doubleday.

Shakespeare W, The History of Troilus and Cressida, The Riverside Shakespeare 2nd.ed. Edited by Dean Johnson, Houghton Mifflin Company, Boston and New York, 1997 pp.477-532

IAHIP 2023 - INSIDE OUT 100 - Summer 2023