Obsessive-Compulsive Disorder Takes Many Forms
What is Compulsive Hoarding?
Hoarding is considered a type
of obsessive-compulsive disorder (OCD). This behavior, also called "pathological collecting," involves acquiring
and saving many objects that may seem useless or of no value. It is not uncommon for people with hoarding OCD to completely
fill their homes with clutter so that the living space is unusable. Early psychoanalysts considered hoarding a sign of
"anal" character traits because of the withholding nature of the behavior.
Hoarders seem to have a unique set of difficulties compared to others. They tend to be more perfectionistic and
indecisive. They have more severe levels of OCD symptoms and more additional psychiatric disorders.
Hoarders may be more likely to have saving and symmetry obsessions. The compulsions involve not only hoarding, but possibly
ordering, counting, and repeating compulsions. Hoarders are more likely to have personality disorders, especially obsessive-compulsive personality disorder and avoidant personality
disorder, a condition similar to social phobia. Not surprisingly, they are more likely to remain single. In addition, more
hoarders have close relatives whom they also describe as pack rats.
seems to be more common in males than females. Hoarders typically have an earlier age of onset of OCD symptoms, and the
symptoms are more severe. Hoarders also have more abnormal grooming behaviors, such as skin picking, nail biting, and trichotillomania
(compulsive hair-pulling). There has been some discussion among researchers that perhaps hoarding is not actually a form
of OCD, but rather a clinically distinct syndrome that is part of the OC spectrum of disorders.
Treatment is Not Easy
challenging aspect of compulsive hoarding is that hoarders often do not recognize they are impaired. Most cases of hoarding
that result in professional attention occur at the request of concerned family members, landlords, or even the legal system.
Hoarders have surprisingly little insight into the potentially dangerous nature of their hoarding behavior. They may even
experience their hoarding as sensible and beneficial.
It does seem that
patients with hoarding symptoms are less responsive to conventional treatments for OCD, such as medication and cognitive-behavior
therapy. Compared to people with other forms of OCD, hoarders tend to experience more anxiety and depression and experience
greater social dysfunction. It could be that treatment of OCD patients with hoarding symptoms is complicated by the fact
that the OCD is more severe and the presence of co-occurring disorders. Nevertheless, improvement is possible using a
flexible approach, with treatment carefully tailored to the patient's specific symptoms.
WHAT IS COMPULSIVE HOARDING?
Compulsive hoarding is a disorder characterized by
difficulty discarding items that appear to most people to have little or no value. This leads to an accumulation of clutter
such that living and workspaces cannot be used for their intended purposes. The clutter can result in serious threats
to the health and safety of the sufferer and those who live nearby. Often people with compulsive hoarding also acquire
too many items - either free or purchased.
In order to meet criteria for a diagnosis of compulsive hoarding,
a person must experience significant distress and/or impairment in functioning as a result of their hoarding behavior.
Common types of functional impairment include: fire or health hazards caused by excessive clutter, infestations, inability
to have guests over to the home, inability to prepare or eat food in the home, inability to find important possessions
because of clutter, inability to finish tasks on time, and interpersonal conflicts caused by the clutter.
Not all hoarding is compulsive. Hoarding and saving behaviors can be seen
in people with various neuropsychiatric disorders, such as psychotic disorders, dementia, eating disorders, autism, and
mental retardation, as well as in people with no psychiatric disorder. However, it is most frequently associated with
obsessive compulsive disorder (OCD). Between 25-40% of people with OCD have compulsive hoarding symptoms. It is not
clear at this point whether compulsive hoarding is part of OCD or whether it is a separate disorder that is common
in people who have OCD.
FREQUENTLY ASKED QUESTIONS:
What typically drives compulsive hoarding?
Discarding valuable items that might be needed
or useful someday
Losing important information
Making a mistake
Losing something that reminds a person of a loved one
Not being able to do things as completely or as well as one would
Typical behaviors seen in
compulsive hoarding include:
far more items than are needed or can be used.
Acquisition of more items than can be used.
Avoidance of throwing things away.
of making decisions.
Avoidance of putting
possessions in appropriate storage areas, such as closets, drawers, or files.
Pervasive slowness or lateness in completing tasks.
What are some other symptoms of compulsive hoarding?
hoarding is part of a discrete clinical syndrome that also includes indecisiveness, perfectionism, procrastination, difficulty
organizing tasks, and avoidance behaviors.
disabling is compulsive hoarding?
Compared to people with non-hoarding OCD, those with compulsive hoarding typically
More functional impairment
More social and family disability
More severe anxiety and depression symptoms
Older age when presenting for treatment
Poor insight into the severity of the problem
The clutter that accumulates in the homes of people who hoard
is often a serious fire risk. These homes are also frequently vulnerable to infestation from rodents, insects, and molds,
which can put the inhabitants of the home at risk for various health problems, including asthma, allergies and infections.
Family members are often frustrated by the gradual worsening of symptoms and the extent of the person's impairment.
They often want very much to help but feel powerless to do so. They may become angry at the person’s inability
to clean or discard clutter, not understanding that this is not possible without treatment.
Are people with compulsive hoarding just lazy?
No. Compulsive hoarding is not due to laziness or weakness of character, nor is it due simply to disorganization.
Rather, the compulsive hoarding syndrome may be due to distinct brain abnormalities that will not improve without
treatment. People with this problem are often acutely aware that the degree of clutter in their home is socially unacceptable
and often believe that others will think them lazy or even crazy. Not surprisingly, they are frequently secretive
about their problems and will often isolate themselves from family and loved ones. This may also be why they are reluctant
to seek treatment.
How many people suffer from compulsive hoarding in the United States?
The true prevalence is unknown, but it is estimated that up to 1.2
million people suffer from compulsive hoarding in the USA.
What causes compulsive hoarding?
Compulsive hoarding may be hereditary. Up to 85% of people with compulsive
hoarding can identify another family member who has this problem. Abnormal brain development and brain lesions may also
play a role. Compulsive hoarding can begin after brain damage, such as strokes, surgery, injuries, or infections.
Family experiences and psychological factors may also play a role in the development of hoarding and emotional stress
may heighten symptoms.
Research indicates that people with the compulsive hoarding syndrome have unique
abnormalities of brain function that are be different from those seen in people with non-hoarding OCD and those with no
psychiatric problems. However, we do not yet fully know what causes these brain abnormalities.
All people with significant hoarding behaviors should receive thorough assessment to evaluate
possible causes of hoarding behavior, determine the correct diagnosis, and develop an appropriate treatment plan.
What is the age of onset of compulsive hoarding?
People with compulsive hoarding who participate in research and treatment
studies have an average age near 50. Onset typically occurs during teenage years, but may occur later in life, after
brain damage, a traumatic life event or episode of depression.
Regardless of the age of onset, there is
usually a significant time lag of many years between the onset of symptoms and when a person first seeks treatment.
What is the course of compulsive hoarding syndrome?
Compulsive hoarding tends to be a chronic disorder. Left untreated,
it usually worsens gradually over time.
What treatments are available for compulsive hoarding?
Cognitive behavior therapy (CBT) using the technique of exposure and
response prevention appears to improve compulsive hoarding symptoms. This technique decreases excessive fears of making
decisions, losing important possessions, throwing things away, and organizing saved items out of sight, by gradual
exposure to tasks that provoke these fears. People with compulsive hoarding problems are encouraged to resist their
urges to engage in their usual behaviors, such as postponing decision making, saving things “just in case,”
or putting things in piles rather than storing them. This ultimately results in a decrease in anxiety, avoidance,
and compulsive behaviors, and changes the way people with compulsive hoarding think about their possessions.
CBT for compulsive hoarding can be effectively done either in someone’s home or in a therapist’s office
Medication – Drugs with potent effects on the
brain chemical serotonin seem most effective. Serotonin reuptake inhibitors (SRI's) are highly effective and FDA-approved
for treatment of OCD, but it is not clear whether they are as effective for compulsive hoarding as for other OCD symptoms.
Very few studies have tested SRI’s or other medications specifically for treatment of compulsive hoarding. Some
studies have found that SRI’s are beneficial for compulsive hoarding, while others found that hoarding symptoms
were associated with poor response to SRI’s.
someone does not have an adequate response to SRI’s, adding other types of medications can often help to improve
response. New medications and new combinations of medications are always being tried, giving reason for greater hope
in the future.
A combination of medication and CBT appears
to be the most effective treatment regimen for most people with the compulsive hoarding syndrome.
Links between Hoarding and Eating Disorders|
Common traits and symptoms and the association with obsessive compulsive disorder
Recently, hoarding has received
a lot of attention. Television shows devoted to the tormented lives of hoarders have been immensely popular with 3.2 million
watching A&E’s “Hoarders” and 1.5 million watching TLC’s “Hoarding: Buried Alive.”
This popularity has created an increase in interest among mental health professionals and the media, including questions about
the root of hoarding and, among the eating disorder community, the question of whether there is a correlation between eating
disorders and hoarding. The common link seems to be in obsessive compulsive tendencies.
Hoarding behavior is closely associated
with obsessive compulsive disorder (OCD); in fact, hoarding is now identified as a type of OCD. Hoarding is a compulsion that
results from excessive concerns that certain objects cannot be discarded because they might be needed later. Hoarders are
more indecisive than those affected with other forms of OCD and tend to experience more anxiety, depression and greater social
dysfunction. According to the University of California - San Diego Compulsive Disorders Clinic, hoarding behavior is found
in 25 to 40 percent of the population diagnosed with OCD.
Obsessive compulsive disorder is also strongly associated with
anorexia nervosa. Serotonin dysfunction has been implicated as one of the possible causes of OCD as well as anorexia
and bulimia nervosa. Various investigators found that OCD was more common in anorexic patients than in the general population,
and anorexia was more common in patients with OCD than in the general population. However, the nature of this relationship
is still being examined.
“The first time I realized the relationship between anorexia nervosa and hoarding came seven years
into treating individuals with eating disorders,” said Deb Kuehnel of Eating Disorder Recovery Center “I see now
that it is quite possible that many of the patients I treated for anorexia nervosa and obsessive compulsive disorder were
Social factors, along with a predisposition to obsessive compulsive illness, influence the development of
anorexia, and social factors also contribute the development of OCD. Along with a food obsession, there is also a focus on
control in both eating disorders and OCD. Preoccupation with control is pervasive in the lives, personality and symptoms
of persons with eating disorders. There are also common personality traits between OCD and anorexia including perfectionism,
excessive orderliness and cleanliness, meticulous attention to detail, stubbornness and rigidity.
With the close association
to obsessive compulsive disorders, patients with eating disorders and hoarding tendencies may be closer than previously noted
in any medical studies. Eating disorders have often been noted in individuals who hoard and vice versa. The two disorders
have common tendencies, including:
“The patient who taught me this [association] initially asked me if I could come to her apartment to see the
gifts she had received over the past 25 years. She greeted me with enthusiasm and then helped me navigate through a narrow
pathway left open between the rooms of her apartment. These gifts were tucked away in their original boxes and she was waiting
for the perfect time to use ‘one or two of them,’” said Deb Kuehnel. “Much like anorexia nervosa,
hoarding is a very serious problem and needs attention. However, therapists need to first develop a trusting relationship.
If you just tell them to stop collecting or try to take their stuff away, they will go out and get more.”
these similarities exist between the behaviors and symptoms of hoarding and eating disorders, there may be a closer genetic
link between the two—exactly what, however, is not clear. Whether this is a genetic predisposition or a behavioral expression,
it is likely that some kind of emotional vulnerability must accompany this tendency in order for full-blown anorexia nervosa,
obsessive compulsive disorder or hoarding to develop.