Hoarding disorder

Hoarders is a television show that depicts people whose homes are overrun with clutter because the occupants can’t get rid of their possessions. Although television may use hoarding for entertainment purposes, it is a disease that causes serious impairment in social and emotional functioning, as well as tasks of daily living.

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Is hoarding a mental illness?

Hoarding is often thought of as a type of obsessive-compulsive disorder (OCD), but it is, in fact, a distinct condition. Hoarding disorder does not get the same attention as some other mental health problems, but maybe it should.

Approximately 2.5% of people suffer from hoarding disorder, making it more prevalent than even OCD. Let’s take a further look at this highly damaging and hard-to-treat mental health condition.

What is Hoarding Disorder?

Hoarding disorder is distinguished by three main aspects:

Difficulty letting go of material possessions.

Excessive acquisition of new items, which can include books, clothing, and even trash.

Lack of organization and an inability to de-clutter. This is likely due to a neurocognitive deficit.

Often, people with hoarding disorder don’t have much insight into their troubles; they may know they have a cluttered space but they don’t think of it as a major problem. In fact, hoarding possessions might give them considerable joy. It is frequently other people that note the difficulty and when hoarding is found out, it can cause considerable shame and embarrassment. As a result, people with hoarding disorder don’t want people in their homes. This leads to social isolation and safety concerns. Home repairs aren’t made and the space becomes unsafe because it is so cluttered. Because of embarrassment, people don’t often report their hoarding behavior, making it an under-diagnosed issue.

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What is the root cause of hoarding?

The causes of hoarding are largely unknown but it appears to have a significant genetic component. Most people with the disorder have a first-degree relative who also suffers from hoarding. Most cases develop in adolescence and the severity of hoarding symptoms increases as people age. This is why the hoarding behavior is frequently not discovered until individuals reach middle age or older.

Executive functioning deficits contribute to the development of hoarding disorder. Difficulties in organization, namely categorizing and decision-making, seem to play a prominent role in hoarding behavior.

People who suffer from hoarding behavior experience great distress at getting rid of their possessions due to the high level of attachment they have developed for these items. They exhibit an inability to tolerate these negative emotions and go to extremes to avoid behavior that brings on feelings of stress or unpleasantness. Although that sounds similar to OCD, it is slightly different. People with OCD feel like something bad will happen if they don’t engage in compulsive behavior. Individuals with hoarding disorder overvalue their materials and simply don’t want to let them go. “One man’s trash is another man’s treasure” perfectly applies to them.

How do you diagnose Hoarding Disorder?

Therapist familiarity with the criteria for hoarding disorder is probably the most common way of diagnosing the condition. However, several more formal assessment instruments have been developed to aid therapists.

These include:

The Saving Inventory-Revised (SIR) is a self-report measure that has three subscales assessing clutter, acquisition, and difficulty throwing items away.

The Hoarding Rating Scale is a brief screening tool that provides a rough measure of hoarding behavior.

The Clutter Image Rating uses pictures of different degrees of clutter to help identify if the problem has reached clinical significance.

What is the most effective treatment for hoarding?

Many people avoid hoarding disorder treatment due to shame and embarrassment. For those that do seek hoarding treatment, the results are mixed at best. While some hoarding disorder treatments help—and new treatments show a lot of potential—no treatments so far have exhibited the ability to reduce hoarding to subclinical levels.

The following are the most common hoarding disorder treatment options:

Cognitive-behavioral treatment (CBT) is the most popular hoarding disorder treatment. CBT involves cognitive restructuring and behavioral interventions, such as exposure. CBT does significantly reduce symptoms but hoarding behavior remains at clinical levels after therapy is complete. It has been suggested that CBT may not be the best fit for hoarders because it relies on cognitive flexibility in individuals with neurocognitive deficits.

Motivational interviewing (MI) is often used in conjunction with other treatments. Individuals with hoarding disorder tend to want to avoid confronting negative emotions and treatment in general. MI is used to help increase motivation toward treatment and combat rates of attrition.

Psychologist Catherine Ayers has created a hybrid treatment for hoarding, called cognitive rehabilitation and exposure/sorting therapy (CREST). It is a mix of exposure, executive functioning training, and cognitive therapy, attempting to address the many facets of hoarding disorder. Although new, it has shown some provisional success as a hoarding disorder treatment.

Peer-run CBT groups and compassion therapy are also promising interventions. These treatments emphasize peer support and the destigmatization of hoarding behavior. Because shame is such an integral part of hoarding, compassion and support are powerful antidotes.

Selective serotonin reuptake inhibitors (SSRIs) have often been prescribed as a hoarding disorder treatment because they work well for OCD. Unfortunately, they have not been as effective in treating hoarding behavior. It has been theorized that stimulant medication might display more effectiveness because hoarding disorder may have more in common with ADHD than it does with OCD.

Hoarding disorder is a highly debilitating condition that causes increasing impairment for people as they age. The behavioral health community would do well to give it more attention, as it is more prevalent than previously thought and stubbornly treatment-resistant.

Resources

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References

Ayers, C. R., Castriotta, N., Dozier, M. E., Espejo, E. P., & Porter, B. (2014). Behavioral and experiential avoidance in patients with hoarding disorder. Journal of behavior therapy and experimental psychiatry, 45(3), 408–414. https://doi.org/10.1016/j.jbtep.2014.04.005

Bratiotis, C., Muroff, J., & Lin, N. X. Y. (2021). Hoarding Disorder: Development in Conceptualization, Intervention, and Evaluation. Focus (American Psychiatric Publishing), 19(4), 392–404. https://doi.org/10.1176/appi.focus.20210016

Dozier, M. E., & Ayers, C. R. (2017). The Etiology of Hoarding Disorder: A Review. Psychopathology, 50(5), 291–296. https://doi.org/10.1159/000479235

International OCD Foundation. Clinical assessment of hoarding disorder. https://hoarding.iocdf.org/professionals/clinical-assessment/

Mathews C. A. (2014). Hoarding disorder: more than just a problem of too much stuff. The Journal of clinical psychiatry, 75(8), 893–894. https://doi.org/10.4088/JCP.14ac09325

OCDUK. Clinical classification of hoarding disorder. https://www.ocduk.org/related-disorders/hoarding-disorder/clinical-classification-of-hoarding-disorder/

Postlethwaite, A., Kellett, S., & Mataix-Cols, D. (2019). Prevalence of hoarding disorder: A systematic review and meta-analysis. Journal of affective disorders, 256, 309-316. https://doi.org/10.1016/j.jad.2019.06.004

Tolin, D. F., & Villavicencio, A. (2011). Inattention, but not OCD, predicts the core features of hoarding disorder. Behaviour research and therapy, 49(2), 120–125. https://doi.org/10.1016/j.brat.2010.12.002

Tolin, D.F., Frost, R.O., Steketee, G. and Muroff, J. (2015), Cognitive Behavioral Therapy For Hoarding Disorder: A meta-analysis. Depression and Anxiety, 32: 158-166. https://doi.org/10.1002/da.22327

Weir, K. (2020, April 1). Treating people with hoarding disorder. Monitor on Psychology, 51(3). https://www.apa.org/monitor/2020/04/ce-corner-hoarding

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