Hoarding Disorder

Have you ever thought that you might be a hoarder because your doll collection is displayed all over your home or because your garage and closets are overflowing with items you just haven’t had time to go through and organize? Did you even know the term “hoarder” before reality TV brought the show Hoarding: Buried Alive into your living room?

Compulsive hoarding affects approximately 4% of the US population and involves the excessive collection of and inability or unwillingness to throw away seemingly useless items. It becomes a mental health disorder when the act of collecting poses a safety and/or health risk, results in limited use of living spaces, and creates significant distress and/or impairment in day-to-day living.

While hoarding has been referred to sporadically in the psychological world since the early 1900s, it made its first formal appearance in the 1980 Diagnostic Statistical Manual of Mental Disorders as one of nine diagnostic criteria for obsessive compulsive personality disorder (OCPD). It wasn’t until the mid-1990s that researchers began to study and understand this complex disorder.

The first definition and systematic study of hoarding was published in 1993 by Frost and Gross. In 1996, Frost and Hardl presented the first empirically based research on this complex disorder in an article that sparked many more research studies over the next decade. Even though the causes of hoarding are unknown, these studies observed four characteristics associated with the development of hoarding:

-Emotional dysregulation: anxiety, depression, and high levels of perfectionism
-Difficulty processing information and problems with attention, memory, and decision making
-Intense emotional attachments to objects that involve attaching humanlike qualities to inanimate objects, experiencing grief when getting rid of objects, and experiencing a sense of safety and happiness when surrounded by possessions
-Beliefs about the necessity of not wasting objects or losing opportunities that are presented by objects

These early studies also found that hoarding has a genetic component, with 50 to 80% of people who hoard having first-degree relatives whom they consider “pack rats” or hoarders.

Hoarding has been classified as a subtype of OCD due to the fears and emotional upset surrounding losing collected objects. However, research has uncovered more differences than similarities between hoarders and people with OCD.

While hoarders typically experience obsessive fears about losing items, the impetus behind hoarding is not a negative, intrusive, or unwanted thought that only the hoarding can relieve, whereas the impetus behind OCD-related behavior is such a thought. In addition, the acquisition of items results in a hoarder feeling pleasure, something that almost never happens when a person with OCD performs a ritual. Hoarders display hoarding-related distress only when being forced to discard an item, and the distress is more like grief than the anxiety seen in a person with OCD.

Research has also found that the most effective forms of treatment for OCD are less effective for hoarders. SSRI (Selective Serotonin Reuptake Inhibitors) medications such as paroxetine (Seroxat or Paxil), fluoxetin (Prozac) or venlafaxine (Effexor), are commonly used to treat depression and anxiety. These medications have been found to be effective in treating people with OCD, while compulsive hoarders show a poor response.

Exposure and response prevention therapy (ERP), as shown on the TV show Hoarding: Buried Alive, is a form of cognitive-behavioral therapy. Using this approach, compulsive hoarders work with their therapists to sift through their belongings and discard whatever they can't rationally justify keeping. The idea behind this treatment is that the more the patient is able to sift and discard, the more he or she habituates to this process. The result is a lowering of anxiety. CBT and ERP have been shown to be effective in treating people with OCD, but less so for people who are compulsive hoarders.

Further, CAT scans of hoarders showed brain activity that is different from people with OCD. In a study published in the August 6, 2012 issue of the Archives of General Psychiatry, researchers at the Institute of Living at Hartford Hospital in Conn., used fMRI machines to measure the brain activity of people when they made decisions about whether to keep or throw away a possession.

The scans of 43 people diagnosed with hoarding disorder, 31 people with obsessive-compulsive disorder (OCD) and 33 healthy individuals were compared. The researchers found abnormal activity in the areas of the brain tied to decision-making in people who had a hoarding disorder.

Because of the many differences between hoarding and OCD that research has uncovered, the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition diagnostic work group on OCD has recommended that hoarding be included in the newest edition of the manual as its own independent clinical disorder. This will have a significant and positive impact on people with Hoarding Disorder as it will lead to more accurate diagnosis, make treatment more accessible, and increase the much-needed research on this complex illness.

Compulsive hoarding can lead to significant safety and health issues for the hoarder and any family members who live in the home. Seeking professional help is vital. To learn more about the signs of compulsive hoarding and to help a friend or family member with this complex disorder, please visit the International OCD Foundation website.