DSM-5 Category: Obsessive-Compulsive and Related Disorders
Hoarding disorder is diagnosed when an individual collects too many possessions and has difficulties discarding those possessions to the extent that the clutter creates significant distress and health and safety risks. Favorite objects of hoarders include newspapers, books, clothes, crafts and junk mail.
Hoarders demonstrate deficits in information processing and attachments to possessions. Neuroscientists have discovered that hoarders have a different way of organizing information. Instead of organizing information by the content/meaning of an item, they will organize based on sight and space. All 8x11 pieces of paper, for example, may be placed in one pile, making it difficult to later find an item.
They are many different types of hoarders – economists, intellects, nostalgics, artists and craftspersons. The most common rationale for hoarding is to avoid waste. The hoarder may also want to economize financially and collect coupons. A hoarder may seek to preserve knowledge through books and newspapers. They are often intelligent and keep information to read in the future. Items to which the hoarder has an emotional attachment are also popular. The person may preserve a reminder of any significant event in his/her life. Crafts are commonly amassed.
The most pronounced symptoms of hoarding are excessive acquisition of possessions, clutter and difficulties discarding the possessions. [i] According to DSM-V, the individual will have a strong urge to save items. The act of hoarding produces feelings of satisfaction and comfort and possibly even euphoria. Ultimately, the accumulating clutter leads to distress (DSM-V). DSM-V further states that the symptoms are not due to a medical condition or other mental disorders. About 50% of those who hoard suffer from clinical depression, which is strongly associated with the negative aspects of hoarding.
Hoarders have difficulties with information processing, including attention focus, organizing and decision-making. These deficits result in a classification of objects that makes it difficult to manage. Sorting paper by size, for example, instead of by content. Hoarding behavior follows a reinforcement cycle. The disorganization and clutter produce negative emotions such as anxiety and frustration. The perception of being unable to manage the clutter leads to avoidance behavior. Rather than discard or organize the clutter, the hoarder seeks the pleasure and excitement of acquiring more items. The hoarder may have symptoms of attention deficit hyperactivity disorder.
Although often connected to obsessive compulsive disorder (OCD), only one in five hoarders have symptoms of OCD whereas as many as 50% of OCD patients may engage in hoarding behavior[ii]. Researchers also fail to make a link between hoarding and life experiences, such as living through a war in which rations were scarce or in poverty as a child.
Impact of Hoarding Disorder on Daily Life
Hoarding behavior can make life difficult for the hoarder and those who live with him/her. The accumulation of clutter that makes living areas unavailable for their intended use is part of the DSM-V criteria. The hoarder’s personal and professional life will often reflect this disorganization. Clinical distress in occupational, social or other areas of functioning caused by the hoarding is now part of the definition under DSM-V. The inefficient organizational skills of hoarders may create frustration and anger when it is difficult to find things. They will require more time to arrange their affairs and may often be late or miss deadlines.
In the home or workplace, hoarding often creates health and safety concerns. The risk of slipping on clutter may be created. Exits may be blocked. One may not be able to easily walk through a room. The clutter may pose a fire hazard, as well as create a buildup of dirt and mold.
Parts of the home will no longer be functional unless a third party intervenes (DSM-V). Surfaces may be occupied such as kitchen counters. Storage spaces may be full, although hoarders have a tendency to want to display as many of their items as they can. Piles may easily topple over. They may resent others in their space interfering with their collection and organization of objects.
Studies of the experiences of family members living with a hoarder identify negative feelings towards the hoarder, barriers to receiving support and feelings of loss[iii]. A lack of understanding of the hoarding behavior can be a source of anxiety and family conflict.
The former classification of hoarding as an OCD encouraged the application of OCD treatments to hoarding, leading to poor outcomes. Some studies have concluded that cognitive behavioral therapy (CBT) applied to hoarding has not produced as strong of outcomes when an OCD-CBT approach is used. Individualized multicomponent treatment programs targeting specific hoarding behaviors have been more successful. One such program combined CBT, psychoeducation, goal setting, and motivation enhancement while also teaching organizing and decision making skills. Regular home visits involved practicing sorting and discarding objects[iv].
Group cognitive behavioral therapy (CBT) has been successful in reducing hoarding behavior and symptoms including depression and anxiety, leading to overall improvement in quality of life.[v] Exposure therapy is sometimes conducted in the home due to the significant disruptions hoarding can cause in home life. A home audit allows for a better understanding of the nature of the disorder. Exposure therapy involves clutter-discarding sessions, and may apply CBT.
Given the potentially significant impact of hoarding on family life, family therapy is a treatment focus area. Approaches include psychoeducational support[vi] and harm reduction training.[vii]
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[i] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
[ii] Ayers, C. R., Saxena, S., Espejo, E., Twamley, E. W., Granholm, E., & Wetherell, J. L. (2013). Novel Treatment for Geriatric Hoarding Disorder: An Open Trial of Cognitive Rehabilitation Paired with Behavior Therapy. The American Journal of Geriatric Psychiatry.
[iii] Sampson, J. M. (2013). The Lived Experience of Family Members of Persons Who Compulsively Hoard: A Qualitative Study. Journal of Marital and Family Therapy, 39(3), 388-402.
[iv] Ayers, C. R., Saxena, S., Espejo, E., Twamley, E. W., Granholm, E., & Wetherell, J. L. (2013). Novel Treatment for Geriatric Hoarding Disorder: An Open Trial of Cognitive Rehabilitation Paired with Behavior Therapy. The American Journal of Geriatric Psychiatry.
[v] Gilliam, C. M., Norberg, M. M., Villavicencio, A., Morrison, S., Hannan, S. E., & Tolin, D. F. (2011). Group cognitive-behavioral therapy for hoarding disorder: An open trial. Behaviour research and therapy, 49(11), 802-807.
[vi] Sampson, J. M., Yeats, J. R., & Harris, S. M. (2012). An Evaluation of an Ambiguous Loss Based Psychoeducational Support Group for Family Members of Persons Who Hoard: A Pilot Study. Contemporary Family Therapy, 34(4), 566-581.
[vii] Tompkins, M. A. (2011). Working with families of people who hoard: a harm reduction approach. Journal of clinical psychology, 67(5), 497-506.