Compulsive Hoarding

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.

 

Hoarding 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

One particularly 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

• Being wasteful

• Losing something that reminds a person of a loved one

• Not being able to do things as completely or as well as one would like

Typical behaviors seen in compulsive hoarding include:

• Saving far more items than are needed or can be used.

• Acquisition of more items than can be used.

• Avoidance of throwing things away.

• Avoidance 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?
Compulsive hoarding is part of a discrete clinical syndrome that also includes indecisiveness, perfectionism, procrastination, difficulty organizing tasks, and avoidance behaviors.

How disabling is compulsive hoarding?
Compared to people with non-hoarding OCD, those with compulsive hoarding typically show:

• 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 setting.

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.

If 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.

Possible 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 likely hoarders.” 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: Indecisiveness Anxiety Depression Social factors/dysfunction Genetic/hereditary links “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.” While 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.