What is Hoarding Disorder?
Hoarding disorder is a long-term and consistent difficulty getting rid of possessions. People who suffer from the disorder accumulate personal possessions and are reluctant to discard them because they believe they might require the items in the future. The accumulated items often have little or no value to anyone but the hoarder. The prospect of discarding the items causes the hoarder profound distress.
In severe cases, the accumulation of items creates inconvenient or unsafe living conditions for the hoarder. Spaces and surfaces fill with items and become unusable, and it is often difficult to move through the hoarder’s living and storage spaces.
Severe hoarding behavior may have significant negative consequences for the sufferer. Their daily functioning may be impaired, and unsafe or unsanitary living conditions can create health problems. In many cases, the hoarder does not recognize the problem and may resist the idea of treatment.
Symptoms of Hoarding Disorder
Symptoms of hoarding disorder often begin in adolescence and start to cause impairment in daily functioning by early adulthood. Symptoms usually reach their peak by middle age. At that point, the sufferer is most likely to meet the criteria for diagnosis of hoarding disorder.
Symptoms of hoarding disorder include:
- Acquiring large amounts of items, even when they have little value and there is no place to store them
- Difficulty discarding or giving away items, even when they have little value
- Distress at the thought of parting with the accumulated items
- Accumulation of items to the point that living spaces become unusable
Differentiation from Collecting
People who collect specialized items may appear similar to hoarders, especially to those who don’t value the items being collected. However, true collectors accumulate their collections logically, and they tend to keep their collections organized. Collecting also does not cause distress or impair daily functioning as hoarding does.
In some cases, the hoarder acquires a large number of pets or other animals. In these cases, the hoarder may accumulate dozens or hundreds of animals. The hoarder is often unable to house and care for the animals properly, creating a situation that is unsafe for both the hoarder and the animals.
What Causes Hoarding Disorder?
Scientists don’t yet know what causes hoarders’ brains to function differently. Several different risk factors appear to increase an individual’s risk of developing hoarding disorder:
- Family history. An individual with one or more relatives who suffer from the disorder is more likely to develop the condition.
- Personality traits. Studies have found a connection between hoarding behavior and certain broad personality traits. Associated traits include indecisiveness, procrastination, avoidance, perfectionism, distractibility, and disorganization.
- Negative life events. In some cases, hoarding behavior begins after the sufferer experiences a traumatic life event such as divorce, unemployment, or the death of a loved one.
- Associated psychiatric disorders. Hoarders often suffer from at least one other mental health problem. Commonly associated disorders include obsessive-compulsive disorder (OCD), major depressive disorder, social anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), and alcohol use disorder.
Is Hoarding Disorder Hereditary?
Prior to the acceptance of hoarding disorder as a separate condition on its own, hoarding behavior was thought to be a symptom of OCD. Studies conducted with this assumption in mind found that OCD sufferers who were hoarders had different patterns of brain activity than those OCD sufferers who didn’t hoard. The studies also found that people who had a family history of hoarding were more likely to suffer from the behavior.
The differences in brain function seemed to be linked to a particular chromosome, a cell structure that contains inherited genetic material. For example, in families with two or more hoarders, individuals had a unique genetic pattern on chromosome 14, whereas OCD sufferers without hoarding behaviors showed a unique pattern on chromosome 3.
These findings suggest hoarding disorder is likely distinct from OCD, and it may be passed down through families. Research into this possibility is ongoing.
How Is Hoarding Disorder Detected?
Early Recognition of hoarding disorder is important because hoarding behaviors tend to get more severe with time. Early detection, diagnosis, and treatment can help get symptoms under control before they have a detrimental impact on the sufferer’s life.
Warning signs of hoarding disorder include:
- Cluttered home and workspaces that are difficult to use
- A tendency to “stock up” on items whenever possible, even when stocking up isn’t necessary
- Collecting “free” items, such as advertising materials, condiments in restaurants, etc.
- Insistence that value-less things are vital or otherwise worth keeping
- Losing or forgetting important items because of the clutter
- Feeling overwhelmed by the clutter
- Embarrassment about the state of living spaces
- Denial of the cluttered condition of living spaces
- Not inviting people into living spaces
- Not allowing service people into living spaces
How Is Hoarding Disorder Diagnosed?
The process of diagnosing hoarding disorder involves conducting assessments of the patient regarding their hoarding behavior. The process may also include interviews with loved ones, caregivers, or others who might have insight into the behavior. The goal of the process is to identify the nature and extent of the behaviors and to rule out other possible causes.
To satisfy a diagnosis of hoarding disorder, the behaviors must fit the following criteria:
- The patient must have persistent difficulty parting with possession, even when the possessions have no value.
- The difficulty must come from a perceived need to keep the items and distress at the thought of discarding them.
- The accumulation of items must have a significant impact on living spaces that hinders the use of the areas.
- The behavior causes distress or impairment of daily functioning.
- The behavior is not attributable to a physical or medical condition.
- The behavior is not a symptom or result of another mental health condition.
The diagnosing mental health professional will assess whether the patient is excessively acquiring items (as opposed to merely saving things in a usual manner), as well as the patient’s level of awareness of their behavior.
PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.
How Is Hoarding Disorder Treated?
Treatment of hoarding disorder usually involves psychotherapy. Cognitive-behavioral therapy (CBT) is the most commonly used therapeutic approach. This type of therapy teaches the sufferer to recognize the thought patterns that underlie their hoarding behaviors. When the sufferer is able to identify the problematic thought patterns, CBT teaches them strategies to cope with the thoughts without resorting to hoarding behavior.
Treatment may also include having the sufferer take steps to declutter their living spaces under the guidance of a therapist or other professional. The sufferer will also be encouraged to develop a plan for future organization and removal of clutter on their own.
No medication is approved for the treatment of hoarding disorder. However, sufferers might sometimes be prescribed medications to treat associated conditions. The most common example is the use of selective serotonin reuptake inhibitors (SSRIs) to treat depression or anxiety.
How Does Hoarding Disorder Progress?
Left untreated, hoarding disorder can eventually lead to a situation where the sufferer’s physical, mental, and social health is placed at extreme risk.
Potential long-term effects of hoarding include:
- Risk of trips and falls
- Risk of being injured by or trapped beneath improperly stored items
- Creation of fire hazards
- Unsanitary conditions that can cause illness or infection
- Problems with family or other relationships
- Social isolation
- Negative impact on work performance
- Poor nutrition (often caused by an inability to use cooking or food storage spaces)
- Legal problems (health code violations, building code violations, etc.)
How Is Hoarding Disorder Prevented?
There is no known way to prevent hoarding disorder. The best way to prevent the adverse effects of hoarding behavior is to watch for the early signs and seek treatment for the sufferer as soon as possible. Treating any co-existing conditions (anxiety, depression, etc.) is likely also to help.
Hoarding Disorder Caregiver Tips
If your loved one is suffering from hoarding disorder, keep these tips in mind:
- Don’t get ahead of your loved one concerning improvement. Hoarders can’t change their behavior until they’re ready to do so independently. If you proceed with decluttering their living space before they’re ready, you’ll be wasting your time. Instead, encourage treatment and be supportive, but allow your loved one to take the lead.
- Be empathetic. We all have an emotional attachment to some objects, and for a hoarding disorder sufferer, the attachment to their possessions is real and strong. So be respectful of their feelings, and don’t throw their things away without permission.
- Focus on the positive aspects of change, rather than the negative results of hoarding. Help your loved one to remember the benefits of controlling their hoarding behavior. Remind them of how they can reach their goals (an improved social life, better family relationships, etc.) if they work on changing their behaviors.
Many people with hoarding disorder also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with HD:
Hoarding Disorder Brain Science
Neuroscientists don’t yet know exactly what brain functions underlie hoarding behavior, but there is evidence that hoarders’ brains behave differently than healthy individuals. One study used functional magnetic resonance imaging (fMRI) to compare brain activity in hoarders, people with non-hoarding OCD, and healthy individuals. The hoarders showed unusual activity in the anterior cingulate cortex, a part of the brain involved in decision-making. The activity was especially pronounced when the hoarders were asked to make decisions about items they owned. In addition, the activity level was directly correlated to the severity of the participants’ hoarding behavior.
Scientists don’t fully understand the function of the anterior cingulate cortex, and its role in the development of hoarding behavior is unclear. However, identifying a unique pattern of brain activity in hoarding disorder is an important step toward developing more effective treatments.
Hoarding Disorder Research
Title: Neural Mechanisms of Decision Making in Hoarding Disorder (LOSS)
Principal Investigator: Carolyn Rodriguez, MD, PhD
Palo Alto, CA
Hoarding disorder is a common and disabling disorder that represents a significant public health problem. This study aims to build on current research on decision-making by examining these processes in hoarding disorder.
Title: Group Treatment for Hoarding Disorder
Contact: Brittany Mathes, MS
Florida State University
The primary aim of this study is to investigate the effectiveness of a novel group treatment for hoarding disorder. Participants will be randomized to receive either treatment as usual (cognitive behavioral therapy: CBT) or treatment as usual augmented by interpersonal psychotherapy (IPT). It is hypothesized that group CBT with IPT will result in greater decreases in hoarding symptoms as compared to standard group CBT. It is further hypothesized that CBT with IPT will result in greater reductions in object attachment and maladaptive beliefs about relationships with others, as well as greater increases in interpersonal attachment.
Title: Cognitive Rehab and Exposure Treatment for Hoarding (CREST)
Principal Investigator: Catherine R Ayers, PhD
VA San Diego Healthcare System
San Diego, CA
Objective: The investigators propose to conduct a randomized controlled trial comparing six months (26 sessions) of Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) treatment to a robust comparator, six months of Exposure Therapy alone, in 136 participants with HD.
Research Design: Assessments will be administered at baseline, during treatment (sessions 7, 13, 21), post-treatment, and 3- and 6-month follow-up; thus, all participants will be enrolled for one year.
Methodology: The primary objective is to evaluate whether CREST significantly reduces hoarding symptoms and improves functional capacity and quality of life compared to exposure therapy alone. The investigators will also examine the impact of treatment mediators; treatment adherence, changes in executive functioning, avoidance, symptom severity on outcomes. Age and executive functioning will also be explored as potential moderators. Finally, by repeatedly measuring treatment targets, the investigators will examine time to maximum treatment effect in an effort to understand mechanisms of change.
Clinical Relationships: By providing a treatment for many Veterans with HD, the investigators can alter the course of their symptom trajectory and negative consequences, resulting in both healthcare costs savings and improved quality of life for Veterans.