The Psychology of Hoarding Disorder: Approaches for Treatment

Many people find it difficult to throw items away in case they might need them later or they are more valuable than they realized. Holding on to possessions we have no use for is a common human trait. However, when it becomes an enduring and distressing behavior, it may be a case of hoarding disorder.

Diagnosing Hoarding Disorder

The diagnosis of hoarding disorder is made when the following criteria are met:¹

• A persistent need to save items
• Clinically significant distress, especially when discarding possessions (regardless of their actual value)
• Clutter and non-functionality in the living space; if the living space is uncluttered, it is only due to third party intervention

Specifiers of the condition include excessive acquisition of new items, good or fair insight, poor insight, and absent insight/delusional beliefs. In addition, these symptoms are not caused or explained by another medical or psychological ailment.

Although hoarding disorder affects 2% to 6% of the population,¹ many individuals do not seek treatment.² According Dr Gregory Chasson, clinical psychologist and associate professor, Illinois Institute of Technology in Chicago, “Treatment ambivalence is the norm, not the exception. Survey research indicates that 85% of individuals with hoarding difficulties acknowledge a need for treatment, yet only about half of those individuals pursue help. Even then, nearly half of individuals with hoarding disorder refuse treatment from the outset, drop out of treatment once it is initiated, or have difficulty fully complying with treatment.”

A deeper understanding of the psychology behind hoarding is needed if treatment ambivalence and non-adherence are to be overcome.

Psychological Ownership Theory

According to Charlene Chu, PhD, assistant professor at Chapman University in Orange, California, “Psychological ownership³ is essentially the feeling ‘it is mine!’ The motives for psychological ownership, namely efficacy and effectance (a tendency to explore and influence one’s environment), self-identity, and a need to have a place within the environment find parallels with emotional attachment to possessions exhibited by individuals with hoarding disorder.”

“Individuals with hoarding disorder exhibit hyper-sentimentality, in which possessions are seen as part of the self, echoing the self-identity motive in psychological ownership, and the use of possessions as safety signals, echoing the motive to have a place/find personal security in psychological ownership,” Dr Chu explained. “In addition, hoarders exhibit a need for control over their possessions, which echoes the efficacy and effectance motivation in psychological ownership. Thus, hoarding may be an extreme form of psychological ownership when viewed through the lens of consumer behavior.”

Psychological ownership theory highlights the extreme ownership experience of a person who hoards, both in terms of the intensity of their feelings and the quantity of items they acquire. Individuals with hoarding disorder also tend to take extreme responsibility for the object — as a part of ownership — and often make statements that express their concern for the well-being of the object. This is a sign of adult anthropomorphism, which research has shown to be a good predictor of hoarding behavior.⁴

The Constructivist Approach

Victoria Barnes of Nottingham Trent University in the United Kingdom sheds light on 2 core aspects of hoarding disorder: valuing items and interacting with them. She interviewed 11 people who identified themselves as having hoarding disorder and found that their stockpiled possessions addressed various psychological needs. They were not seen as useless items, but rather as valuable items with which they interacted. Interviewees were proud to be valuing items that others might not appreciate. Indeed, they often saw themselves as “temporary custodians” of the items.⁵

Barnes is developing a theoretical model of hoarding based on some of the key reasons behind these behaviors:

• Documenting personal history
• Preserving the past
• Holding on to the memory of loved ones
• Relief of anxiety related to past material deprivation
• Preventing feelings of isolation and loneliness
• Physical security, with possessions acting as a barrier for intruders
• Avoiding hurting the feelings of items (anthropomorphism)

Attachment Theory

Early anxious attachments can lead to the avoidance of human interaction and the replacement of human relationships with objects. Individuals with hoarding disorder often have excessive emotional reactivity, and negative emotions can be slow to decline in response to interpersonal stressful events. This brings to the forefront a lack of emotional regulation skills and the need to manage these emotions by acquiring more objects.⁶ As the number of traumatic or stressful events increases, so does the severity of hoarding.⁷

Treatment Pathways

While pharmacotherapy research has revealed some promising findings,^8-12 cognitive behavioral therapy (CBT) remains the gold standard for hoarding disorder treatment.¹³

Chasson explains: “Three primary components of CBT for hoarding disorder are: (1) exposure and response prevention, (2) executive function skill development (eg, sorting and organization skill development), and (3) cognitive therapy techniques.” For the latter, the irrational value placed on objects shows information processing deficits that decrease with CBT.¹⁴ Cognitive rehabilitation with exposure/risk therapy has shown benefits, particularly in older people who hoard.¹⁵

 “Treatment motivation is a primary consideration in CBT for hoarding disorder,” Chasson noted. “A harm reduction approach is often more palatable than a values-laden approach and preserves a patient’s motivation for change. For example, harm reduction would revolve around improving home safety (eg, removing papers from on top of the toaster), whereas a values-laden approach would instead focus on helping the individual because the home is ‘not the right way to live’ or ‘embarrassing.’” 

Dr Chu recommends applying psychological ownership theory to understanding how to encourage consumers in general to dispose of possessions. She says, “As people with hoarding disorder are strongly motivated to feel psychological ownership, attempts to ‘decrease’ psychological ownership may not be welcome. Rather, methods that ‘extend’ psychological ownership, that allow one to maintain feelings of ownership even after discarding the object, may prove more effective. For example, taking photos of objects prior to disposal may help to sustain psychological ownership of objects.”³

Conclusion

Hoarding disorder is one of many conditions that have been trivialized over the years, but research demonstrates the very real distress that comes with the condition, both for patients and for family members. Fortunately, as the gap between psychiatry and psychology is bridged, more integrated and efficient treatment models are being tested.

References  

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Press, 2013.
2. Chasson GS, Guy AA, Bates S, Corrigan P W. (2018). They aren’t like me, they are bad, and they are to blame: a theoretically-informed study of stigma of hoarding disorder and obsessive-compulsive disorder. J Obsessive Compuls Relat Dis. 2018;16:56-65.
3. Chu CK. Psychological ownership in hoarding. In: Psychological Ownership and Consumer Behavior. Cham: Springer; 2018:pp 135-144.
4. Burgess AM, Graves LM, Frost RO. My possessions need me: anthropomorphism and hoarding. Scand J Psychol. 2018;59(3):340-348.
5. Kinman G. Revenge porn and hoarding. The British Psychological Society. https://thepsychologist.bps.org.uk/revenge-porn-and-hoarding. Updated May 14, 2018. Accessed July 23, 2018.
6. Grisham JR, Martyn C, Kerin F, Baldwin PA, Norberg MM. Interpersonal functioning in hoarding disorder: an examination of attachment styles and emotion regulation in response to interpersonal stress. J Obsessive Compuls Relat Dis. 2018;16:433-449.