Hoarding is a mental disorder characterized by excessive accumulation of possessions and persistent difficulty in discarding or otherwise parting with possessions of little or no value. Hoarding is an anxiety disorder that is often considered to be a form of obsessive-compulsive disorder (OCD).
Hoarding is a complex disorder of three related issues:
Hoarding typically begins in childhood or adolescence and becomes progressively more severe over the decades, until the home may be filled with clutter, leaving little room to move about and seriously impeding daily functioning. The accumulation can spread to vehicles, garages, and yards. Hoarding can have a direct and extremely stressful effect on others living in the home. It can lead to unsanitary conditions, the risk of falls or other injuries, family conflicts, poor work performance, financial and/or legal problems, an inability to perform daily activities such as cooking or bathing, and loneliness or social isolation. Some people hoard animals, with dozens or hundreds of pets that cannot be properly cared for. Hoarding sometimes leads to serious safety concerns, including fire, public health, or child or animal welfare issues. People with hoarding disorder often fail to see it as a problem, which makes treatment challenging. Hoarding sometimes occurs in association with other disorders, such as dementia, autism, and eating disorders.
Hoarding characters have long appeared in fiction. In Russian psychiatry, hoarding is referred to as “Plyushkin syndrome,” after a character in a nineteenth-century Russian novel by Nikolai Gogol. In the early twentieth century, William James (1842–1910) described acquisitiveness as an instinct that was part of self-identity. Erich Fromm (1900–1980) also suggested that acquisition was intrinsic to character, but that “hoarding orientation” was one of the four types of dysfunctional character. Sigmund Freud (1856–1939) described hoarding money as a fixation at the anal stage of development, and other psychoanalysts expanded this to include the hoarding of objects. In 1980, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) defined hoarding as one of the nine diagnostic criteria for obsessive-compulsive personality disorder. That same year, “pop psychology” writer Sandra Felton foundedMessiesAnonymous.Self-helpbooksforhoarding began appearing, and a new career—professional organizing—emerged. Significant research into hoarding began about 1996, and twenty-first-century reality TV brought hoarding into the public spotlight.
Although many mental-health professionals continue to view hoarding as a form of OCD, by the 1990s, researchers were describing hoarding as more closely associated with indecisiveness, perfectionism, emotional attachment to possessions, organizational problems, and information-processing deficits than with other symptoms of OCD. In 2013, the DSM-5 reclassified hoarding as its own disorder under the chapter “Obsessive-Compulsive and Related Disorders.” Various studies have demonstrated differences in brain activity patterns between hoarders and people with OCD, as well as healthy people. Hoarding is similar to OCD in that difficulties with discarding appear to be driven, at least in part, by obsessive fears, such as fear of losing significant information or something with emotional significance or causing a bad outcome, such as behaving wastefully. However, at least 80% of hoarders do not have other symptoms of OCD. Compared to people with non-hoarding forms of OCD, people with hoarding disorder:
The prevalence of pathological hoarding is estimated at 2–5% of the population—affecting between 6 million and 15 million Americans. The true prevalence may be higher, since hoarding is often done in secret, and many hoarders never seek treatment. Hoarding disorder can affect anyone at any age, although late-onset after age 40 is rare. Hoarding behaviors typically begin by about age 13, although the disorder often is not recognized until late life. Since psychiatric disorders generally decrease in later life, it has been suggested that hoarding is the only mental disorder other than dementia that increases in prevalence and severity throughout life. Older adults also are more likely to live alone, with fewer pleasurable diversions, and may recall periods of deprivation when accumulation was a necessity. Hoarding may be more common among men than women. About half of older adults with hoarding disorder have other psychiatric disorders, especially major depression, as well as other mood and anxiety disorders. There are an estimated 3,000–5,000 cases of animal hoarding detected in the United States each year, involving up to 250,000 animals.
Three out of four hoarders accumulate by excessive shopping, and about one-half excessively collect free items. Although anything can be hoarded, clothing, newspapers, and books are the most commonly hoarded items. Hoarders also accumulate items such as food wrappers and packing materials. However, the hallmark of hoarding is the inability to discard and becoming overwhelmed if discarding is attempted. Most hoarders are also unable to organize their possessions. Hoarding is chronic and increases with age, but most hoarders do not recognize it as a serious problem; they commonly believe that they are behaving normally. Hoarding rises to the status of a psychiatric disorder when acquisition, clutter, and disorganization affect a person's health or safety or cause significant distress, although hoarding often causes more distress to friends and family than to the hoarders themselves. People with hoarding disorder are often socially isolated and may have difficulty performing daily activities.
The DSM-5 criteria for a hoarding disorder diagnosis include:
Family members or friends are often the first to contact a mental-health provider with concerns about hoarding. Diagnosis is based on a psychological evaluation and questions about acquiring and discarding items, emotional well-being, and signs of other disorders, such as OCD, depression, or an anxiety disorder. The provider may ask to speak with friends or relatives. There are several specific diagnostic tools:
Treatment for hoarding is challenging, because patients often do not believe that they have a problem or need treatment. They tend to have little motivation and frequently drop out of treatment. Furthermore, when possessions or animals are removed, people with hoarding disorder often collect more very quickly. Cognitive-behavioral therapy (CBT) is the only treatment that has been shown to help with hoarding symptoms. In one study, CBT that included office visits and inhome sessions focusing on acquisition, problems discarding, and disorganization, yielded responses in 50–70% of patients after 26 sessions. In several studies, exposure and response prevention (ERP)—a standard CBT treatment for OCD that focuses on quickly discarding items without careful inspection—had little effect on hoarding. In other studies, ERP was effective for mid-life but not late-life hoarders. In general, patients with hoarding disorder appear to prefer exposure treatment that includes very specific, concrete tasks.
Medications such as selective serotonin reuptake inhibitors (SSRIs) are usually ineffective for hoarding disorder, as well as for OCD with hoarding symptoms; however, in one study, 28% of patients with hoarding disorder responded to the SSRI paroxetine. Sometimes antipsychotic medications are used in conjunction with SSRIs to attempt to treat hoarding.
Self-management for hoarding disorder includes:
See also Cognitive-behavioral therapy; Obsessive compulsive disorder.
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Anxiety and Depression Association of America, 8701 Georgia Ave., Ste. 412, Silver Spring, MD, 20910, (240) 485-1001, Fax: (240) 485-1035, http://www.adaa.org .
International OCD Foundation, PO Box 961029, Boston, MA, 02196, (617) 973-5801, Fax: (617) 973-5803, IOCDFhoarding@ocfoundation.org, https://iocdf.org .