In the following paper, I shall discuss Hoarding Disorder, an anxiety disorder that was previously seen as a subcategory of OCD (Maxmen & Ward, 1995). Since the publication of the DSM 5, Hoarding Disorder is now regarding as distinct disorder and not subcategory of OCD—albeit a related anxiety disorder (DSM 5, 2014). More specifically, I will describe the typical behavior and the subjective experience of those with the disorder, as well as its etiology, symptoms, diagnostic criteria, and treatments.
As stated above, the focus of this paper is hoarding. Although previously the general consensus among mental health professionals was that hoarding disorder was a subcategory of OCD, hoarding was found to have many unique aspects that differentiate it from of OCD (Sansone & Sansone, 2010). For example, response to medications, compliance with treatment, and severity of impairment in daily functioning all strongly distinguish hoarders from those with OCD (Sansone & Sansone, 2010). OCD may be diagnosed in people who exhibit hoarding behaviors if the failure to discard items comes as the result of obsessions and compulsions, such as saving items to avoid the stress that may come from an endless checking ritual (for example, having to check over and over again if an item is broken before throwing it away). In general, those with OCD find the behaviors associated with their symptoms unpleasant in contrast to people with hoarding who typically are less distressed by their saving behaviors and symptoms (DSM 5, 2014).
Seedat and Stein pointed out that hoarding is usually not preceded by obsessional thoughts and anxiety; however, they experience this when they are prevented from hoarding or when their possessions are discarded (2002). Furthermore, hoarders tend to show a different pattern of comorbidity than those with OCD with a greater likelihood of social phobia, generalized anxiety disorder, specific phobias, bipolar II disorder, dysthymia, personality disorders, and pathological grooming disorders, as well as less insight into their disorder than those with OCD (Saxena, 2007).
In a recent study, 40% of hoarders reported depression, 15% compulsive shopping, and 10% compulsive gambling. Alcoholism and personality disorders are relatively common, as well. Comorbidity seems to be the norm for people diagnosed with Hoarding Disorder (Sansone & Sansone, 2010). It is also important to rule out disorders which may have more of an organic neurological cause when diagnosing hoarding disorder, since hoarding may be found in those with dementia, schizophrenia, and developmental disabilities (Marchand & McEnany, 2012).
Not all people who excessively save items and have cluttered homes qualify for hoarding that is essentially pathological. Some individuals are just poorly organized and never seem to find time to throw away unwanted items. In contrast, those with hoarding disorder experience great anxiety when confronted with throwing away items (Marchand & McEnany, 2012). For example, they often believe that throwing away items will equate to some sort of catastrophe. Those who are simply unorganized would not be highly distressed if some of their useless items were thrown away (Maxmen & Ward, 1995).
Etiology, Symptoms, and Typical Behavior
Seedat and Stein define compulsive hoarding as “the repetitive collection of excessive quantities of poorly useable items of little or no value with failure to discard these items over time (2002).” Hoarding exists along a continuum from mildly disruptive to completely incapacitating. Commonly hoarded items include letters, magazines, old clothes, newspapers, and receipts. In extreme cases, however, garbage, animals, or anything, with which a patient comes into contact, may be hoarded (Marchand & McEnany, 2012).
According to Seedat and Stein’s study, hoarders cited sentimental value (60%) and symbolic value (13%), while 27% saw no value in their hoarded items (2002). Most compulsive hoarders attribute practical value to their saved items. In other words, they believed that they would be able to put their items to good use at some future time. In fact, many fear not having needed items in the future and, therefore, hang on to everything (Seedat & Stein, 2002).
In the early stages, hoarders may be simply unorganized, with an acceptable amount of clutter in their homes (Sansone & Sansone, 2010). In some cases, the degree to which one hoards may reach a plateau and remain stable over time. In other cases, in continually worsens until it which reaches debilitating proportions. However, hoarding has also been reported to occur rather suddenly after some acute life stressor in those who had not previously hoarded (Seedat & Stein, 2002).
Common characteristic among hoarders are miserliness and difficulty separating themselves from objects in their possession (Sansone & Sansone, 2010). They often display saving behaviors, indecisiveness, perfectionism, procrastination, poor organizational skills, and avoidance behaviors (Saxena, 2007). Additionally, they have diminished insight into their disorder. In other words, they do not feel that they have a problem or recognize the problems associated with excessive hoarding (Sansone & Sansone, 2010). Hoarders tend to rationalize the excessive clutter in their homes, believing that if they just had more space for storage, there would be no problem (Singh & Jones, 2013). Although some admit that their hoarding is excessive, they rarely resist the urge to hoard (Singh & Jones, 2013). “Most report little to no control of their hoarding (Seedat & Stein, 2002).”
As is the case with OCD, depression is common among hoarders. Due to the nature of compulsive hoarding, hoarders experience more social isolation, problems with family, and occupational impairment. Hoarders tend to be embarrassed by their living environment and do not like having company; thus, leading to a more socially isolated lifestyle (Saxena & Maidment, 2004). Indeed, there is a great deal of shame and guilt associated with Hoarding Disorder, especially since recently popular media tends to portray in a very negative light. The stigma associated with Hoarding Disorder often makes it more difficult for those with the disorder to enter treatment (Sansone & Sansone, 2010).
Those who are employed feel forced to lead a “double life” out of fear that their coworkers will discover their living situation. This isolation and the anxiety associated with their lifestyle inevitably leads to a greater occurrence of depression (Sansone & Sansone, 2010). Indeed, “ hoarders show more anxiety, depression, family and social disability, and dependent and schizotypal personality disorders compared with those with OCD and patients with [other] anxiety disorders (Seedat & Stein, 2002).”
According to the DSM 5, “approximately 75% of individuals with hoarding disorder have a comorbid mood or anxiety disorder (DSM 5, 2014).” Furthermore, it may have some genetic component. Approximately, 50% of hoarders report having a family member who is also a hoarder (DSM 5, 2014).
Hoarding seems to occur more frequently in elderly, unmarried, socially isolated women (Neziroglu, 2004). It is three times more likely to occur in older adults than young adults (DSM 5, 2014). On the other hand, in earlier research, Greenberg reported that hoarding, in general, affects all socioeconomic classes, as well as males and females relatively equally (1987). Recent research indicates that it is more common in women than men (DSM 5, 2014).
As mentioned above, hoarders are often embarrassed by their living environment. Their homes are filled with clutter, ranging from excessive to extreme. For example, some hoarders may have stacks of old newspapers and magazines piled in every corner of their homes, while others may have to virtually crawl through their homes or weave through narrow passageways due to the extreme amount of clutter that has literally filled their homes from top to bottom. Living spaces become useless or uninhabitable by most people’s standards. Stoves may be piled high to the ceiling with useless objects or trash, so food preparation becomes nearly impossible. Likewise, beds can become just another place for storage; therefore, there are no appropriate places for sleeping (Neziroglu, 2004).
In addition to filling their homes with huge amounts of clutter, hoarders sometimes begin to pile their belongings outside their homes, on porches, in their yards, or even on the streets and sidewalks outside their apartment building. Since hoarders are reluctant to seek out treatment, social workers, public health officials, and the Humane Society may only become aware of the hoarders’ situation after neighbors complain about junk/eyesores in the hoarders’ yard or foul odors emitting from the hoarders’ homes (Greenberg, 1987).
As stated above, hoarders may reside in unhealthy and unsanitary living quarters. Since navigating an extremely cluttered home is difficult, hoarders (especially elderly hoarders) are at increased risk for injuries due to tripping and falling over clutter, or even from objects falling on them. Rotting garbage and food, as well as animal excrement can emit toxic fumes and cause respiratory problems (Seedat & Stein, 2002). Many hoarders suffer from gastrointestinal problems and allergies, additionally (Berry & Schell, 2006). Furthermore, hoarders may not even be able to properly bathe, since bathrooms can become filled with clutter. Fires from excessive clutter coming into contact with heaters are a common risk factor for hoarders, as well. Such health hazards are particularly concerning when dependents (elderly relatives or children) reside within the household (Saxena & Maidment, 2004).
The causes of hoarding are not clearly understood. Some hoarders were ardent collectors as children, collecting baseball cards or coins, for example (albeit in a healthy manner) (Dozier & Ayers, 2013). Seedat and Stein claim that some hoarders felt deprived of both material possessions and meaningful relationships as children (2002). For example, some hoarders report that their parents did not allow them to keep possessions. Hoarders often report some sort of traumatic event that preceded the development of hoarding disorder (DSM 5, 2014).Temperamentally, hoarders are often indecisive and have difficulty making and carrying out plans (DSM 5, 2014).
Furthermore, many hoarders have relatives who also hoarded or had OCD, which may suggest a genetic component to the disorder (Singh & Jones, 2013). In fact, Saxena reportedly found a genetic marker on chromosome 14 that my predispose one to OCD hoarding (2007). Siblings are also more likely to share hoarding symptoms than non-hoarding siblings (Saxena, 2007). “One study found that 84% of compulsive hoarders reported a family history of hoarding behaviors in at least one first-degree relative, but only 37% reported a family history of OCD (Dozier & Ayers, 2013).” According to Seedat and Stein, more research is needed on hoarding in order to gain a more accurate understanding of the disorder (2002).
The DSM 5 lists the following six symptoms as diagnostic criteria for Hoarding Disorder:
- a) Persistent difficulty discarding or parting with possessions, regardless of their actual value. b) This difficulty is due to a perceived need to save the items and to desires associated with discarding them. c) The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). d) The hoarding causes clinically significant distress or impairment in social, occupational or other important areas of functioning (including maintaining a safe environment for self and others). e) The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome). f) The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in OCD, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder) (DSM 5, 2014).
The DSM 5 also includes the following specifiers: “With excessive acquisitions; With good or fair insight; With poor insight; With absent insights/delusional beliefs (2014).”
Perhaps a more simple way to conceptualize Hoarding Disorder involves the following: (1) saving items of limited or no value, (2) saving items disrupts social, occupational, and daily functioning, with or without unhealthy living conditions, (3) anxiety when confronted with throwing away saved items, (4) indecisiveness, perfectionism, and procrastination may be evident, (5) little to no motivation to stop saving items, (6) little insight into the problems associated with excessive saving, and (7) does not seek out treatment and/or inadequately complies with treatment (Singh & Jones, 2013).
Treatment and Prognosis
Typically treatments for compulsive hoarding include SSRI’s, SSNRI’s and cognitive-behavioral counseling. A recent study showed that 37% of participants showed a reduction in hoarding behaviors 12 weeks after beginning SSRI medications. SSRI medications are less effective when administered without cognitive-behavioral counseling (Saxena & Maidment, 2004). Unfortunately, hoarders tend to show a low compliance rate for taking prescribed medications (Sansone & Sansone, 2010).
Cognitive-behavioral treatment for hoarders focuses on decreasing the amount of clutter in their homes, improving organizational skills, improving decision making regarding which possessions should be kept or thrown away, and overall reducing the urge to save. Under the supervision of their therapist, patients are encouraged to throw away one item at a time. The idea is to gradually desensitize the patient to the act of discarding items. Eventually, patients will be encouraged to throw away more and more items. In time, hoarders are taught to think differently about their attachments to their possessions (Saxena & Maidment, 2004).
The use of visual aids, such as videos and pictures of cluttered homes show promise when combined with CBT. For example, clients are shown pictures and videos asked to describe what happened to lead to the home becoming so cluttered. In this way clients are able to analyze hoarding behaviors in order to gain insight into their own hoarding behaviors (Dozier & Ayers, 2013).
Keeping patients busy in structured activities and in the company of others also tends to reduce hoarding. When hoarders are faced with fines imposed by lawmakers, they may try to reduce their hoarding somewhat, as well (Dobrian, 2015). Other medications that may be effective in treating hoarding include “cognitive enhancers such as donepezil or glutamine, which increase cholinergic neurotransmission in the cerebral cortex, or stimulant medications, which can increase the functioning of medial prefrontal cortical areas involved in attention and executive functioning (Saxena & Maidment, 2004).”
Hoarding Disorder is a chronic and debilitating disorder, which may lead to other psychopathologies, such as depression (Dozier & Ayers, 2013). Although in the past it was classified as a subtype of OCD, recent research has led the DSM 5 to list it as a distinct and separate disorder. Hoarding is a poorly understood disorder, and more research is needed on it in order to develop better treatments. For now, cognitive-behavioral therapy seems to be the best choice for treating this disorder (Saxena & Maidment, 2004). Because hoarders are embarrassed and secretive about their situation, they rarely present themselves for treatment. Public health officials are most often the first people to discover a hoarder (Seedat & Stein, 2002). Perhaps, more collaboration between public health officials and mental health professionals is needed to ensure that compulsive hoarders get proper help in dealing with their disorder.
American Psychiatric Association. (2014). Diagnostic and Statistical Manual of Mental Disorders: DSM 5 (5th ed.). Arlington: Amer. Psychiatric Assn.
Dobrian, J. (2015). The ten ton problem and the elephant in the room. JPN, March, 17-21.
Dozier, M., & Ayers, C. (2013). Hoarding in late life: Implications for clinicians. Psychiatric
Greenberg, D. (1987). Compulsive hoarding. American Journal of Psychotherapy 41,409-416.
Marchand, S., &McEnany,G. (2012). Hoarding’s place in the DSM-5: Another symptom,
or a newly listed disorder. Issues in Mental Health Nursing, 33:591–597.
Maxem, J. S., & Ward, N. G. (1995). Essential psychopathology and its treatment. (2nd.). New York: W.W. Norton and Company.
Neziroglu, F., & Bubrick, J., & Yaryura-Tobias, J. A. (2006). When keeping stuff gets out of hand. Harvard Women’s Health Watch, March, 4-5.
Sansone, R., & Sansone, L. (2010). Hoarding: Obsessive symptom or
Syndrome. Psychiatry, 7: 24-27.
Saxena, S., & Maidment, K. M. (2004). Treatment of compulsive hoarding. JCLP/In Session, 60, 1143-1154.
Saxena, S. (2007). Is compulsive hoarding a genetically and neurobiological discrete syndrome? Implications for diagnostic classification. American Psychiatry, 164, 380-384.
Seedat, S., & Stein D. J. (2002). Hoarding in obsessive compulsive disorder and related disorders: A preliminary report of 15 cases. Psychiatry and Clinical Neurosciences, 56, 12-23.
Satwant, S., & Jones, C. (2013). Compulsive hoarding syndrome: Engaging patients in treatment. Mental Health Practice, 17: 16-20.