Weill Medical College of Cornell University
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Obsessive Compulsive Hoarding

By Randy Frost, Ph.D. and Gail Steketee, Ph.D

Reprinted with permission by the Obsessive Compulsive Disorder Support Group of Christchurch, New Zealand. Newsletter No. 63, February/March 2001

Hoarding is a little studied and not very well understood behaviour. It involves the acquisition of and failure to discard possessions that appear to be useless or of limited value. The behaviour is quite common, and many people who hoard possessions do not suffer from a disorder. However, when this behaviour becomes severe, it can cause significant distress and impairment. Hoarding behaviour becomes clinically significant when it creates sufficient clutter so that parts of one's home cannot be used for their intended purpose. The problems caused by hoarding include safety and health threats, as well as interpersonal and even legal conflicts. Navigating a cluttered house can be dangerous, especially for older people or those with limited mobility. Excessive clutter is frequently associated with increased risk of fire and difficulty exiting the home due to blocked doorways and windows. Because inadequate cleaning of cluttered homes is difficult, if not impossible, allergies and respiratory disorders can be exacerbated by hoarding behaviour. In some cases, saving rotten food or contaminated food containers poses additional health-related concerns, the extreme clutter often associated with hoarding frequently creates interpersonal conflict with those living in the home and may result in social isolation. Disorganization observed in the homes of people with this problem creates financial difficulties because finding and paying bills is frequently a problem. Such chaotic living conditions can create significant generalized distress as well.

Is hoarding a symptom of OCD?
Twenty to thirty percent of people diagnosed with OCD report hoarding as a major symptom. However, hoarding is associated with other disorders as well, such as anorexia nervosa, post-traumatic stress disorder (PTSD), dysphoria, dementia, and obsessive personality disorder (OCPD), for which it is one of the diagnostic criteria. In the mid 1970's researchers suggested a syndrome of behaviors in the elderly that included hoarding, self-neglect and neglect of immediate surroundings. It was named Diogenes Syndrome after a 4 th century BC Athenian Cynic who rejected all domestic comforts. Most often, however, hoarding is a symptom of obsessive compulsive disorder. Whether hoarding in the context of OCD differs from hoarding in the context of the other disorders just described is unknown. In fact, recently investigators have suggested that many patients thought to have Diogenes Syndrome actually have undiagnosed OCD. Sometimes hoarding appears in conjunction with other OCD symptoms, such as washing and checking fears and rituals, and sometimes it appears alone. It is not clear whether hoarding in the context of OCD is different from hoarding that is part of OCPD. In the DSM-IV criteria for OCPD, hoarding is said to involve solely items without sentimental value, though this assumption appears to be erroneous.

Who typically has OCD hoarding?
People who are identified as having a problem with compulsive hoarding tend to be somewhat older than other OCD patients though most indicate that their hoarding behaviour started When they were young. Consequently the average age of onset for this problem is unknown. Nonpathological hoarding behaviour may occur early in life and at some point, perhaps as possessions accumulate, the hoarding behaviour becomes more difficult to control. It is not clear whether this problem affects women more than men. Most studies of compulsive hoarding include more women than men, but this may merely be because women volunteer for such studies more often than men.

Why do people with this problem save things?
The obsessional fear associated with hoarding is that something of importance might be lost by discarding. The feared loss may be in the form of monetary value, lost opportunity, or even the loss of part of oneself. Discarding or giving away possessions can provoke grief-like reactions in people who hoard. Fears about loss are related to beliefs commonly seen in other forms of OCD. For instance, people who hoard often feel an exaggerated sense of responsibility for being prepared and for not wasting resources. These beliefs can be so powerful that the relative importance of objects is exaggerated. People who hoard tend to want to maintain control over their possessions, often so that no harm will come to them or so that they are given only to people who will take proper care of them. People who hoard also overestimate the threat posed by discarding a possession, typically fearing criticism from others or being unprepared. Finally, efforts to discard are accompanied by lack of tolerance for the uncertainty that a use may be found tomorrow for a possession that was discarded yesterday. Hoarding is associated with several other characteristics that are part of the clinical picture. Most people who hoard are often highly perfectionist, and excessively concerned with making mistakes. These mistakes typically concern the idea that something important will be discarded, with serious repercussions. People who hoard also have problems with making decisions, not merely decisions about possessions, but also about minor events such as what to wear and what to order in a restaurant. These problems may result from difficulties attending to, organizing, and weighing information relevant to a decision. Hoarding behaviour appears to run in families. This suggests that it may be influenced by modeling or possibly that it is genetically transmitted. While some have suggested that hoarding is associated with deprivation early in life, there is as yet no scientific data to support this hypothesis.

Who else gets involved in cases of hoarding?
In cases where the health and safety of the individual or their family are concerned, local departments of health or social service agencies frequently become involved. In some cases, the result is eviction or seizure of possessions and their disposal by local authorities. In such cases, the immediate health and safety risks may be reduced, but the clutter is frequently recreated in a short time. Housing is a particular area of concern for people who hoard. For those who rent, worry that the landlord will start eviction proceedings is a constant threat. For people who own a home, allowing repairmen into the house is often a problem. Elder service agencies frequently are involved in trying to help elderly hoarders who want to continue living on their own.

How is compulsive acquisition related?
Hoarding is nearly always accompanied by excessive acquisition of possessions. This may include both compulsive buying as well as the compulsive acquisition of free things. For example, a person who hoards may visit the post office daily to acquire unclaimed newspapers or magazines. Frequently, people who hoard are unable to refrain from buying bargains, even though they have no use from them. Other forms of compulsive acquisition include picking up extra handouts, brochures or other free things, and even picking through dumpsters or other people's trash. Compulsive acquisition is also linked to fears of losing something or making mistakes, in this case about things not yet in their possession.

What other problems are associated with hoarding? In addition to excessive acquisition and problems discarding, hoarding is characterized by problems with organization. People who hoard are rarely able to organize their possessions to prevent clutter, and the process of organizing and putting items away seems difficult and fraught with anxiety. Hoarding may be accompanied by attention deficit disorder, so that organizing and discarding are especially troublesome tasks because the individual is easily distracted from routine tasks. In addition, those who hoard also commonly experience significant depression, especially when their lives are substantially disrupted by this behaviour. Social phobia and isolation also occur more frequently than would be expected by change.

What types of treatment are appropriate?
Hoarding may be more difficult to treat than other forms of OCD for several reasons. People with this problem have a hard time recognizing the problem or its seriousness, and state that they prefer to live in a cluttered space rather than give up their potentially valuable possessions. Consequently motivation to change is sometimes limited. Also, by the time the problem has become serious enough to warrant help, the volumes of possessions would pose a problem even for people who do not have problems deciding what to discard. For those who recognize the problem and want to do something about it, cognitive behaviour therapy designed specifically for hoarding has shown some initial promise as an effective treatment. This approach involves working on behaviors associated with hoarding (e.g., organization), as well as cognitive aspects of the disorder such as emotional attachments to possessions, worries about putting objects out of sight, and erroneous beliefs about the nature and function of possessions as well as decision-making skills. It should be noted that while this approach has shown initial promise in several case studies and case series, more research is needed to establish its efficacy. People seeking help with this problem may also wish to try medication, however, there is as yet little evidence that the serotonergic medications that have proved so helpful for OCD are effective in the treatment of hoarding.

Randy Frost, Ph.D., is Professor of Psychology at Smith College (U.S.A). Gail Steketee, Ph.D., is Professor, Associate Dean of Academic Affairs at Boston University, School of Social Work (U.S.A).

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