Managing Hoarding Disorder

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The understanding of hoarding has evolved in recent years. It is now recognized as being more common than previously thought, with an estimated prevalence between 2% and 5%.1-3 Hoarding is a significant public health burden and presents a safety hazard for both the patient and his or her neighbors.4  

Classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR)5 as a criterion for obsessive-compulsive personality disorder (OCPD) and a symptom of obsessive-compulsive disorder (OCD), it is now classified in DSM-5 as hoarding disorder (HD), a distinct entity under the category, “Obsessive Compulsive and Related Disorders.”6

Table 1. DSM-5 Diagnostic Criteria for Hoarding Disorder
  1. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
  2. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
  3. 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 (eg, family members, cleaners, or the authorities).
  4. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining an environment safe for oneself or others).
  5. The hoarding is not attributable to another medical condition.
  6. The hoarding is not better explained by the symptoms of another mental disorder (eg, obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, etc).
  7. Specifiers
    1. With excessive acquisition
    2. With good or fair insight
    3. With poor insight
    4. With absent insight/delusional beliefs
Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).6

How Does HD Differ From OCD?

Areas of apparent similarity exist in OCD and HD, according to Randy Frost, PhD, Professor of Psychology at Smith College in Northampton, Massachusetts.

Fear of making mistakes in what to keep or discard, or fear of losing potentially important or valuable items seem similar to “obsessions,” while urges to save or acquire new items seem similar to “compulsions.” Individuals with HD become distressed when their possessions are touched or moved without their permission, resembling the distress individuals with OCD might experience under similar circumstances.7

But there are significant differences between the two conditions, Frost told Psychiatry Advisor.

Presence or absence of intrusive thoughts

In OCD, obsessions are “repeated, intrusive thoughts,” while in HD, thoughts related to keeping or acquiring items are not perceived as intrusive or unwanted.7 The word “preoccupation” might be a more appropriate term than “obsession.”8

Distressing nature of thoughts

In OCD, intrusive thoughts are experienced as distressing. However, in HD, distress results from the byproduct of the thoughts and behaviors (eg, the judgments of others) rather than from the thoughts or behaviors themselves.7

Is there an attempt to get rid of the thoughts?

One of the hallmarks of OCD is the frequent need to perform rituals to vanquish unwanted thoughts or behaviors. In HD, the thoughts and behaviors are pleasurable. Distress, grief, or anger can occur when individuals with HD face the prospect of potentially discarding an object, rather than by the presence of the objects themselves.7

Natural course of the condition

In HD, symptoms worsen with each decade of life, although distress and disability are more likely to increase in later life, often as a result of the intervention of families or authorities.9-1

Degree of insight

Typical patients with OCD—with the exception of those whose predominant symptoms include symmetry and ordering—have insight into their condition. This is not the case with most patients with HD. Acquisition, accumulation, and saving are associated with pleasure and fulfillment without insight into why this might be considered dysfunctional.7

Symptoms of OCD

While some patients with OCD patients experience clinically significant symptoms of hoarding, many (if not most) patients with HD do not display other symptoms of OCD.7,12 A study of patients with severe hoarding compared two groups according to the presence or absence of OCD. Only approximately one-quarter of those with severe hoarding who also met diagnostic criteria for OCD actually had “traditional” obsessions or compulsions, such as fear of catastrophic consequences if items were discarded, need to perform rituals associated with discarding, or need to buy items in certain numbers.13

HD can also occur comorbidly with other psychiatric conditions, such as depression and attention-deficit/hyperactivity disorder (ADHD).14

Neurophysiology of Hoarding

The regions of the brain primarily associated with hoarding seem to be the anterior cingulate cortex (ACC) and associated areas.15 The dorsal ACC is associated with decision making, error monitoring, and reward-based learning, while the ventral ACC, which is connected to limbic structures, aids in assigning “emotional and motivational salience and experiences.”15 Both positron emission tomographic and functional magnetic resonance imaging studies have found that ACC activation is lower in hoarding individuals than in healthy individuals and non-hoarding individuals with OCD.16,17

Motives for Hoarding

Emotional/sentimental attachment is a central motive for hoarding, said Frost. The person anthropomorphizes the possession, believing that he or she will “hurt the feelings” of the possession by discarding it. Other motives concern the use of possessions (“you never know when it can come in handy”) or worry about information or memory loss (“if I discard this, I will forget its content or the event it represents”).

Contrary to Frost's expectations, HD was not found to be associated with material deprivation early in life, although many individuals with HD are concerned about wasting. “Deprivation plays a part in only a small percentage of individuals with HD,” he said.

According to Frost, individuals with HD have an “excessive attachment to objects, almost as if these items are extensions of themselves.” He further describes, “I have heard patients with HD use terms such as ‘violation' and even ‘rape' when their possessions were moved or touched.”

Diagnosing HD

Individuals with HD rarely self-report, Frost observed. And as typical intake assessments do not usually include specific questions about hoarding, HD frequently goes unnoticed.

“Be proactive about asking about daily life in patients with anxiety,” Dr Frost emphasized. “Look for clues. For example, people with HD lose common functions in their home. Their refrigerators break and do not get fixed because they are afraid of allowing others, such as repairmen, into their homes.”

Patients with suspected HD can be asked to complete the Clutter Image Rating, the UCLA Hoarding Severity Scale,18 or the Savings Inventory (revised) (SIR). Links to these scales can be found at: http://www.hoarders.org/rpr.html.

Pharmacologic and Nonpharmacologic Management

Research investigating pharmacotherapies for HD is limited. Open-label trials of venlafaxine19 and paroxetine20 yielded promising results in improving symptoms of hoarding, but further research is required.

Specific HD-focused cognitive behavioral therapy21,22 developed by Dr Frost and colleagues “has shown good outcomes.” Facilitative self-help groups have also been successful. The facilitator's guide to “Leading the Buried in Treasures Workshops” is provided by the International OCD Foundation and helps in the creation and implementation of self-help workshops for individuals with HD. 

“Sometimes, it is easier for a patient with HD to go to a self-help group than to a therapist,” Dr Frost observed.

Families of individuals with HD experience distress and often attempt to intervene, but their attempts are usually unsuccessful.23 Reliable resources for family and caregivers can be found at: http://www.hoarders.org/f-c.html.

Conclusion

“The depiction of hoarders in popular television series makes them look like freaks, but all of us display some of these traits,” observed Frost. “We keep the ticket stub from a favorite concert, although there is nothing in its physical characteristics to distinguish it from any other ticket stub. We apply meaning to it because it is associated with a special event.” Understanding HD in others is easier if we recognize the same tendencies in ourselves.

Batya Swift Yasgur MA, LMSW, is a psychotherapist and freelance writer who lives in Teaneck, NJ. She practices therapy in New York City.

References

  1. Iervolino AC, Perroud N, Fullana MA, et al. Prevalence and heritability of compulsive hoarding: a twin study. Am J Psychiatry. 2009;166(10):1156-1161.
  2. Mueller A, Mitchell JE, Crosby RD, et al. The prevalence of compulsive hoarding and its association with compulsive buying in a German population-based sample. Behav Res Ther. 2009;47(8):705-709.
  3. 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.
  4. Frost RO, Steketee G, Tolin DF, et al. Motives for acquiring and saving in hoarding disorder, OCD, and community controls. J Obsessive Compuls Relat Disord. 2015;4:54-59.
  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Press; 2000.
  6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Press, 2013.
  7. Mataix-Cols D, Frost RO, Pertusa A, et al. Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety. 2010;27:556-572.
  8. Rachman S, Elliott CM, Shafran R, Radomsky AS. Separating hoarding from OCD. Behav Res Therapy. 2009;47:520-522.
  9. Grisham JR, Frost RO, Steketee G. Hoarding and obsessive-compulsive symptoms. Behav Modif. 1996;20:116-132.
  10. Ayers CR, Saxena S, Golshan S, Wetherell JL. Age at onset and clinical features of late life compulsive hoarding. Int J Geriatr Psychiatry. 2009;25:142-149.
  11. Dozier ME, Porter B, Ayers CR. Age of onset and progression of hoarding symptoms in older adults with hoarding disorder. Aging Ment Health. 2015; Apr 24:1-7. [Epub ahead of print]
  12. Samuels JF, Bienvenu OJ, Grados MA, et al. Prevalence and correlates of hoarding behavior in a community-based sample. Behav Res Ther. 2008;46:836-844.
  13. Pertusa A, Fullana MA, Singh S, et al. Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both? Am J Psychiatry. 2008;165:1289-1298.
  14. Hall BJ, Tolin DF, Frost RO, Steketee G. An exploration of comorbid symptoms and clinical correlates of clinically significant hoarding symptoms. Depress Anxiety. 2013;30(1):67-76.
  15. Grisham JR, Baldwin PA. Neuropsychological and neurophysiological insights into hoarding disorder. Neuropsychiatr Dis Treat. 2015;11:951–962.
  16. Tolin DF, Stevens MC, Villavicencio AL, et al. Neural mechanisms of decision making in hoarding disorder. Arch Gen Psychiatry. 2012;69:832-841.
  17. An SK, Mataix-Cols D, Lawrence NS, et al. To discard or not to discard: the neural basis of hoarding symptoms in obsessive-compulsive disorder. Mol Psychiatry. 2009;14(3):318-331.
  18. Saxena S, Ayers CR, Dozier ME, Maidment KM. The UCLA Hoarding Severity Scale: development and validation. J Affect Disord. 2015;175:488-493.
  19. Saxena S, Sumner J. Venlafaxine extended-release treatment of hoarding disorder. Int Clin Psychopharmacol. 2014 Sep;29(5):266-273.
  20. Saxena S, Brody AL, Maidment KM, Baxter LR Jr. Paroxetine treatment of compulsive hoarding. J Psychiatr Res. 2007;41(6):481-487.
  21. Muroff J, Steketee G, Frost RO, Tolin DF. Cognitive behavior therapy for hoarding disorder: follow-up findings and predictors of outcome. Depress Anxiety. 2014;31(12):964-971.
  22. Tolin DF, Frost RO, Steketee G, Muroff J. Cognitive behavioral therapy for hoarding disorder: a meta-analysis. Depress Anxiety. 2015;32(3):158-166.
  23. Chasson GS, Carpenter A, Ewing J, et al. Empowering families to help a loved one with hoarding disorder: pilot study of Family-As-Motivators training. Behav Res Ther. 2014;63:9-16.

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