Hoarding disorder is common and potentially disabling. It is characterized by persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions. Hoarding often extends to the point that objects cover the living areas of the home and cause significant distress or impairment.1
This behavior usually has harmful effects—emotional, physical, social, financial, and even legal—on the person who has the disorder and on family members. It can also potentially limit the living space and put the hoarder and others at risk for fires, falls, poor sanitation, and other health concerns. People who hoard are often conscious of their irrational behavior, but the emotional attachment to the hoarded objects far exceeds the motive to discard the items.1
In some studies, hoarding has been listed as one of the diagnostic criteria for obsessive-compulsive personality disorder (OCPD), and clinicians may consider extreme hoarding a diagnostic marker for OCPD.2 However, regardless of the historical link between hoarding, obsessive-compulsive disorder (OCD), and OCPD, hoarding behavior frequently seems to be independent of the above neurologic and psychiatric disorders.2
Whether hoarding would continue to be described as a symptom of another disorder such as OCD or OCPD, or classified as a separate disorder in the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was the subject of discussion for several years. It was determined that there was sufficient evidence to recommend the creation of a new disorder called hoarding disorder. It was anticipated that the creation of this new diagnosis in the DSM-5 would, over the years, be likely to increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder.2, 3
This article takes a closer look at hoarding signs and symptoms, etiology, and possible treatments.
SIGNS AND SYMPTOMS
It has been estimated that 2% to 5% of adults exhibit hoarding behaviors. Hoarding behaviors can begin as early as the teenage years, although the average age of a person seeking treatment for hoarding is about 50 years. People who hoard often endure a lifelong struggle, and patients tend to live alone or with family members with the same problem. In certain populations, hoarding problems are present in at least 1 in 20 people.3
The inability to get rid of items is the main symptom of hoarding (Sidebar, Hoarding vs. Collecting). Other signs and symptoms include having a large amount of clutter in the office, at home, in the car, or in other spaces that makes it difficult to use furniture or appliances or move around easily; losing important items like money or bills in the clutter; feeling overwhelmed by the volume of possessions that has taken over the house or work space; being unable to stop taking free items, such as advertising flyers or sugar packets from restaurants; buying things because they are a bargain; not inviting family or friends into the home out of shame or embarrassment; and refusing to let people into the house to help or make repairs. Some hoarders keep a large number of animals, such as cats or birds, and fail to provide them with proper care.3
Other signs and symptoms include difficulty organizing possessions, unusually strong positive feelings of delight when getting new items, strong negative feelings of fear and anger when considering getting rid of items, and strong beliefs that items are “valuable” or “useful” even when other people do not want them. Hoarders commonly deny any problems, even when clutter clearly interferes with their life.3
ETIOLOGY AND RISK FACTORS
Hoarding appears to be more common in people with psychological disorders such as depression, anxiety, alcohol dependence, and attention-deficit-hyperactivity disorder (ADHD). People who hoard often do not recognize their behavior as a problem, which makes it harder for therapists to successfully treat hoarding behavior. Study results show that hoarders are significantly less likely to see a problem in a hoarding situation than a friend or relative might. This is independent of OCD symptoms, as OCD patients are often very aware of their disorder.4
People who hoard may think that their behavior comes from having lived through a period of poverty or hardship during their lives. Research to date has not supported this idea. However, experiencing a traumatic event or serious loss, such as the death of a spouse or parent, may lead to a worsening of hoarding behavior.4
Severe clutter threatens the health and safety of those living in or near the home, causing health problems, structural damage, fire, and even death. Hoarding also causes conflicts with family members and friends who are frustrated and concerned about the state of the hoarder’s home.4
TREATMENT
Successful hoarding treatment requires the patient to have a high degree of motivation and commitment. Attempts to clean out the homes of people who hoard without treating the underlying problem usually fail. Families and community agencies may spend many hours clearing a home only to find that the problem recurs, often within just a few months. Hoarders whose homes are cleared without their consent often experience extreme distress and may become further attached to their possessions; this may lead to the refusal of help in the future.5
The primary treatments for compulsive hoarding include psychotherapy, pharmacotherapy, and a combination of both.
Psychotherapy
Strategies to treat hoarding include challenging the hoarder’s thoughts and beliefs about the need to keep items and about collecting new things; going out without buying or picking up new items; and getting rid of and recycling clutter. The first step is to practice the removal of clutter with the help of a clinician or coach. Second, hoarders may wish to find and join a support group or team up with a coach to sort and reduce clutter. The final step is to understand that relapses can occur and develop a plan to prevent future clutter.5
Cognitive-behavioral therapy (CBT) is one treatment strategy for hoarding. CBT looks at four main problem areas: information-processing deficits, problems in forming emotional attachments, behavioral avoidance, and erroneous beliefs about the nature of possessions. CBT for compulsive hoarding is then directed toward decreasing clutter, improving decision-making and organizational skills, and strengthening resistance to urges to save.5
Time-limited group cognitive-behavioral therapy (GCBT), which has demonstrated improvement for people with OCD, has also shown benefits for hoarders. This has become a significant psychological therapy in recent years, with research studies demonstrating the feasibility and modest success of GCBT methods in improving hoarding symptoms. Group treatment may be especially valuable because of its cost-effectiveness, greater client access to trained clinicians, and reduction in social isolation and stigma linked to this problem. Further research is needed to improve the efficacy of GCBT methods for hoarding and to examine durability of change, predictors of outcomes, and processes that influence change.6
Behavioral counselors typically use the following guidelines when a person is willing to talk about a hoarding problem: Acknowledge that people have a right to make their own decisions at their own pace; remember that everyone has some attachment to the things they own; and offer ideas to make the home safer, such as moving clutter from doorways and halls. Counselors team up with clients who hoard and refrain from arguing about whether to keep or discard an item. Instead, counselors identify what will help motivate the person to discard items and organize. Developing trust and having sympathy and respect for the person who hoards are critical.5
Attempts by family and friends to help with decluttering may not be well received by a hoarder. It is important to know that until the person is internally motivated to change, he or she may not accept any offer for help. Motivation cannot be forced, and everyone, including people who hoard, has a right to make choices about their objects and how they live.5,6
People who hoard can be encouraged to recognize that hoarding behavior interferes with the goals or values they have. For instance, if a person who hoards desires a richer social life, decluttering the home may enable the person to host social gatherings.
The combination of cognitive rehabilitation and exposure therapy is also a promising approach in the treatment of hoarding in older adults.6
Pharmacotherapy
Studies have shown that OCD patients will respond well to selective serotonin reuptake inhibitor (SSRI) medications, and some of these drugs have also been found effective in patients with hoarding behavior.7
In a 2011 study by Sanjaya Saxena, MD, that included 79 OCD patients, of 32 of whom had compulsive hoarding syndrome, all participants received paroxetine 20 mg (Paxil) alone for a mean of 80 days. Both groups improved significantly with treatment of OCD symptoms, hoarding, depression, and anxiety; this result contradicts the results of previous studies that indicated compulsive hoarding does not respond well to SSRI treatment.8 The study concluded that SSRIs appear to be as effective for hoarders as for non-hoarding OCD patients.9
Venlafaxine is an SSRI as well as a norepinephrine reuptake inhibitor at higher doses. Preliminary results with venlafaxine suggest a good response with hoarding behaviors in some individuals, with a trend for greater reduction in hoarding symptoms than that seen with paroxetine.7
New treatment strategies might include cognitive enhancers such as donepezil or galantamine, which increase cholinergic neurotransmission in the cerebral cortex. Stimulant medications can increase the functioning of medial prefrontal cortical areas involved in attention and executive functioning.8
Symptom improvement from pharmacotherapy for compulsive hoarding appears to be at least as good as that resulting from CBT.8 It is now thought that the combination of pharmacotherapy and CBT for compulsive hoarding is likely more effective than either treatment alone.8
In addition to the above treatment strategies, research is focused on finding functional brain abnormalities and information-processing deficits that appear to underlie hoarding disorder. A new type of transcranial magnetic stimulation (TMS), which is a noninvasive magnetic field to stimulate nerve cells in certain regions of the brain to treat mood control and depression, may work for people with hoarding disorder.9
Other clinicians have sought new approaches to identify cerebral metabolic patterns specifically associated with compulsive hoarding syndrome using positron emission tomography (PET). This research has compared regional cerebral glucose metabolism between OCD patients with and without compulsive hoarding, as well as normal subjects. OCD patients with compulsive hoarding had a different pattern of cerebral glucose metabolism (significantly lower glucose metabolism) than nonhoarding OCD patients (significantly higher glucose metabolism) in relation to comparison subjects. Across all OCD patients, hoarding severity was negatively correlated with glucose metabolism in the dorsal anterior cingulate cortex.10
CONCLUSION
Hoarding disorder can occur in the context of several developmental, neurologic and psychiatric behaviors. Clinically significant hoarding is prevalent and can vary from mild to life-threatening. Hoarding recently met the criteria to qualify as a new disorder in DSM-5 called hoarding disorder in order to remove any ambiguities and clearly separate it from hoarding as a compulsion in OCD and or OCPD. This condition was previously classified as a symptom of OCD and patients received treatments designed for OCD.
The public and personal health consequences of hoarding are substantial, and the disorder is generally considered difficult to treat. However, hoarding disorder in highly motivated patients can be improved by pharmacologic (SSRIs) and psychological therapies or a combination of both.
REFERENCES
1. Pertusa A, Frost RO, Fullana MA, et al. Refining the boundaries of compulsive hoarding: a review. Clin Psychol Rev, 2010;30:371-386.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington,VA: American Psychiatric Association; 2013.
3. Mataix-Cole D, Frost RO, Pertusa A, et al. Hoarding disorder: a new diagnosis for DSM-V. Depress Anxiety, 2010;27:556-572.
4. Samuels JF, Bienvenu OJ, Grados MA, et al. Prevalence and correlates of hoarding behavior in a community-based sample. Behav Res Ther. 2008;46(7):836-844.
5. Grisham JR, Brown TA, Savage CR, et al. Neuropsychological impairment associated with compulsive hoarding. Behav Res Ther. 2007;45:1471-1483.
6. Muroff J, Steketee G, Rasmussen MA, et al. Group cognitive and behavioral treatment for compulsive hoarding: a preliminary trial. Depress Anxiety. 2009;26:(7)634-640
7. Saxena S, Summer J. Venlafaxine extended-release treatment of hoarding disorder. Int Clin Psychopharmacol. 2014;5:266-273.
8. Saxena S. Pharmacotherapy of compulsive hoarding. J Clin Psychol. 2011;67(5):477-484.
9. Saxena S. Pharmacotherapy of compulsive hoarding. In: RO Frost, Steketee G, eds. The Oxford Handbook of Hoarding and Acquiring. New York, NY: The Oxford University Press; 2014.
10. Saxena S, Brody AL, Maidment KM, et al. Cerebral glucose metabolism in obsessive-compulsive hoarding, Am. J Psychiatry. 2004;161:(6)1038-1048.
11. Nordsletten AE, Mataix-Cols D. Hoarding versus collecting: where does pathology diverge from play? Clin Psychol Rev. 2012;32-165-176.
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