Hoarding

**Compulsive hoarding**, also known as **hoarding disorder**, is a behavioral pattern characterized by excessive acquisition of and an inability or unwillingness to discard large quantities of objects that cover the living areas of the home and cause significant distress or impairment. Compulsive hoarding behavior has been associated with health risks, impaired functioning, workplace impairment, economic burden, and adverse effects on friends and family members. When clinically significant enough to impair functioning, hoarding can prevent typical uses of space, enough so that it can limit activities such as cooking, cleaning, moving through the house, and sleeping. It can also put the individual and others at risk of fires, falling, poor sanitation, and other health concerns.

Researchers have recognized compulsive hoarding as a phenomenon since at least the 1980s, but only recently have begun to study hoarding, and it was first defined as a mental disorder in the 5th edition of the DSM in 2013. It was not clear whether compulsive hoarding is a separate, isolated disorder, or rather a symptom of another condition, such as OCD, but the current DSM lists hoarding disorder as both a mental disability and a possible symptom for OCD. Prevalence rates have been estimated at 2% to 5% in adults, though the condition typically manifests in childhood with symptoms worsening in advanced age, at which point collected items have grown excessive and family members who would otherwise help to maintain and control the levels of clutter have either died or moved away. Hoarding appears to be more common in people with psychological disorders such as depression, anxiety and attention deficit hyperactivity disorder (ADHD). Other factors often associated with hoarding include alcohol dependence and paranoid, schizotypal and avoidance traits.

## Signs and symptoms

Compulsive hoarding in its worst forms can cause fires, unsanitary conditions such as rat and cockroach infestations and other health and safety hazards.

Listed below are possible symptoms hoarders may experience:

* They hold onto a large number of items that most people would consider useless or worthless, such as:
	+ Advertising mail, old catalogs, magazines, and newspapers
	+ Worn out cooking equipment
	+ Things that might be useful for making crafts
	+ Clothes that might be worn one day
	+ Broken things or trash
	+ "Freebies" or other promotional products
* Their home is cluttered to the point where many parts are inaccessible and can no longer be used for intended purposes. For example:
	+ Beds that cannot be slept in
	+ Kitchens that cannot be used for food preparation
	+ Tables, chairs, or sofas that cannot be used for dining or sitting
	+ Unsanitary bathrooms
	+ Tubs, showers, and sinks filled with items and can no longer be used for washing or bathing
* Their clutter and mess is at a point where it can cause illness, distress, and impairment. As a result, they:
	+ Do not allow visitors in, such as family and friends, or repair and maintenance professionals, because the clutter embarrasses them
	+ Are reluctant or unable to return borrowed items
	+ Keep the shades drawn so that no one can look inside
	+ Get into a lot of arguments with family members regarding the clutter
	+ Are at risk of fire, falling, infestation, or eviction
	+ Often feel depressed or anxious due to the clutter

### Obsessive-compulsive disorder

For many years, hoarding has been listed as a symptom or a subtype of obsessive-compulsive disorder (OCD) and obsessive–compulsive personality disorder (OCPD). Obsessive-compulsive disorder is a type of anxiety disorder. People with OCD experience unwanted thoughts that incline them to do something repetitively. Some of these behaviors are excessive cleanliness and excessive toothbrushing. The current DSM says that an OCD diagnosis should be considered when:

* The hoarding is driven by fear of contamination or superstitious thoughts
* The hoarding behavior is unwanted or highly distressing
* The individual shows no interest in the hoarded items
* Excessive acquisition is only present if there is a specific obsession with a certain item

Compulsive hoarding does not seem to involve the same neurological mechanisms as more familiar forms of obsessive–compulsive disorder and does not respond to the same drugs, which target serotonin. In compulsive hoarding, the symptoms are presented in the normal stream of consciousness, and are not perceived as repetitive or distressing like in OCD patients. Despite statistics indicating that there is a prevalence of hoarding in 18% to 40% of patients with OCD, only 5% of compulsive hoarders experience symptoms of OCD. In another study, a sample of 217 patients diagnosed with significant hoarding, only 18% were diagnosed with OCD, as opposed to the 36% that were diagnosed with a major depressive disorder. There are significant differences and issues between the diagnostic features of compulsive hoarding and OCD which are being considered in a possible addition to the DSM-V of a new independent disorder such as compulsive hoarding. It is also said that there may be an overlap with a condition known as impulse control disorder (ICD), particularly when compulsive hoarding is linked to compulsive buying or acquisition behavior.

Recent findings suggest that there may be three types of hoarding: pure hoarding, hoarding plus OCD (i.e., co-morbid OCD), and OCD-based hoarding. Given the aforementioned distinction, it was proposed to increase coverage of compulsive hoarding in the forthcoming Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), both by creating a distinct category for compulsive hoarding, provisionally named, Hoarding Disorder (either in the main manual under "obsessive-compulsive spectrum disorders" or in the appendix), and by including hoarding as a potential symptom of OCD.

### Book hoarding

Main articles: Bibliomania
Bibliomania is a disorder involving the collecting or hoarding of books to the point where social relations or health are damaged. One of several psychological disorders associated with books (such as bibliophagy or bibliokleptomania), bibliomania is characterized by the collecting of books which have no use to the collector nor any great intrinsic value to a more conventional book collector. The purchase of multiple copies of the same book and edition and the accumulation of books beyond possible capacity of use or enjoyment are frequent symptoms of bibliomania.

One of the most famous bibliokleptomaniacs in American history, Stephen Blumberg, never felt that he was doing anything wrong. "Blumberg was trying to save a forgotten world from a system (the libraries) that neglected it." Another was Gustav Hasford. (See Gustav Hasford#Library books theft charges.)

### Animal hoarding

Main articles: Animal hoarding

Animal hoarding involves keeping larger than usual numbers of animals as pets without having the ability to properly house or care for them, while at the same time denying this inability. Compulsive animal hoarding can be characterized as a symptom of a disorder rather than deliberate cruelty towards animals. Hoarders are deeply attached to their pets and find it extremely difficult to let them go. They typically cannot comprehend that they are harming their pets by failing to provide them with proper care. Hoarders tend to believe that they provide the right amount of care for their pets. The American Society for the Prevention of Cruelty to Animals provides a "Hoarding Prevention Team," which works with hoarders to help them attain a manageable and healthy number of pets. Along with other compulsive hoarding behaviors, it is linked in the DSM-IV to obsessive–compulsive disorder and obsessive–compulsive personality disorder. Alternatively, animal hoarding could be related to addiction, dementia, or even delusional disorder.

Animal hoarders display symptoms of delusional disorder in that they have a "belief system out of touch with reality." Many hoarders lack insight regarding the extent of deterioration their habitation and the health of their animals undergo, and tend not to recognize that anything is wrong. Delusional disorder is an effective model in that it offers an explanation of hoarders' apparent blindness to the realities of their situations.

Another model that has been suggested to explain animal hoarding is attachment disorder, which is primarily caused by poor parent-child relationships during childhood. As a result, those suffering from attachment disorder may turn to possessions, such as animals, to fill their need for a loving relationship. Interviews with animal hoarders have revealed that hoarders often experienced domestic trauma during childhood, providing evidence for this model. Perhaps the strongest psychological model put forward to explain animal hoarding is obsessive–compulsive disorder.

The Animal Legal Defense Fund provides an online resource addressing ways, from a legal standpoint, to stop or prevent animal hoarding. It covers civil options for stopping animal hoarders, cost mitigation laws, and sentencing including mandatory forfeiture.

## Mechanism

Some evidence based on brain lesion case studies also suggests that the anterior ventromedial prefrontal and cingulate cortices may be involved in abnormal hoarding behaviors, but sufferers of such injuries display less purposeful behavior than other individuals who hoard compulsively, thus making the involvement of these brain structures unclear. Other neuropsychological factors that have been found to be associated with individuals exhibiting hoarding behaviors include slower and more variable reaction times, increased impulsivity, and decreased spatial attention. A study comparing neural activity in hoarders, people with OCD, and a control group when deciding to throw possessions away found that when hoarders were trying to decide to throw away their own possessions, they had lower activity in the anterior cingulate cortex and insula regions of the brain. The study suggested this lower activity was related to "problems in identifying the emotional significance of a stimulus, generating appropriate emotional response, or regulating affective state during decision making." Hoarders had normal levels of activity in those regions when making decisions about possessions that did not belong to them.

The opposite condition is compulsive decluttering.

## Diagnosis

The DSM-5 diagnostic criteria for hoarding disorder are:

1. Persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions. (The Work Group is considering alternative wording: "..., regardless of their actual value.")
2. This difficulty is due to strong urges to save items and/or distress associated with discarding.
3. The symptoms result in the accumulation of a large number of possessions that fill up and clutter active living areas of the home or workplace to the extent that their intended use is no longer possible. If all living areas become decluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).
4. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).
5. The hoarding symptoms are not due to a general medical condition (e.g., brain injury, cerebrovascular disease).
6. The hoarding symptoms are not restricted to the symptoms of another mental disorder (e.g., hoarding due to obsessions in Obsessive-Compulsive Disorder, decreased energy in Major Depressive Disorder, delusions in Schizophrenia or another Psychotic Disorder, cognitive deficits in Dementia, restricted interests in Autism Spectrum Disorder, food storing in Prader–Willi syndrome).

Understanding the age of onset of hoarding behavior can help develop methods of treatment for this “substantial functional impairment." Hoarders pose danger to not only themselves, but others as well. The prevalence of compulsive hoarding in the community has been estimated at between 2% and 5%, significantly higher than the rates of OCD, panic disorder, schizophrenia, and other mental disorders.

751 people were chosen for a study in which people self-reported their hoarding behavior. Of these individuals, most reported the onset of their hoarding symptoms between the ages of 11 and 20 years old, with 70% reporting the behaviors before the age of 21. Fewer than 4% of people reported the onset of their symptoms after the age of 40. The data shows that compulsive hoarding usually begins early, but often does not become more prominent until after age 40. Different reasons have been given for this, such as the prominence of family presence early in life and the extent of limits and facilitates they have on removing clutter. The understanding of early onset hoarding behavior may help in the future to better distinguish hoarding behavior from “normal” childhood collecting behaviors.

A second key part of this study was to determine if stressful life events are linked to the onset of hoarding symptoms. Similar to self-harming, traumatized persons may create "a problem" for themselves in order to avoid their real anxiety or trauma. Facing their real issues may be too difficult for them, so they "create" a kind of "artificial" problem (in their case, hoarding) and prefer to battle with it rather than determine, face, or do something about their real anxieties. Hoarders may suppress their psychological pain by "hoarding." The study shows that adults who hoard report a greater lifetime incidence of having possessions taken by force, forced sexual activity as either an adult or a child, including forced intercourse, and being physically handled roughly during childhood, thus proving traumatic events are positively correlated with the severity of hoarding. For each five years of life the participant would rate from 1 to 4, 4 being the most severe, the severity of their hoarding symptoms. Of the participants, 548 reported a chronic course, 159 an increasing course and 39 people, a decreasing course of illness. The incidents of increased hoarding behavior were usually correlated to five categories of stressful life events.

Although excessive acquiring is not a diagnostic criterion of hoarding, at least two-thirds of individuals with hoarding disorder excessively acquire possessions. Having a more anxiously attached interpersonal style is associated with more compulsive buying and greater acquisition of free items and these relationships are mediated by stronger distress intolerance and greater anthropomorphism. Anthropomorphism has been shown to increase both the sentimental value and perceived utility of items. These findings indicate that individuals may over-value their possessions to compensate for thwarted interpersonal needs. Feeling alone and/or disconnected from others may impair people's ability to tolerate distress and increase people's tendencies to see human-like qualities in objects. The humanness of items may increase their perceived value and individuals may acquire these valued objects to alleviate distress.

### Differential diagnosis

Collecting and hoarding may seem similar, but there are distinct characteristics between hoarders and collectors that set them apart. Collecting often involves the targeted search and acquisition of specific items that form—at least from the perspective of the collector—a greater appreciation, deeper understanding, or increased synergistic value when combined with other similar items. Hoarding, by contrast, appears haphazard and involves the overall acquiring of common items that should not be especially meaningful to the person who is gathering such items in large quantities. People who hoard commonly keep items that hold little to no true meaning or value to most others, unlike some collectors, whose items may be of great value to select people. Most hoarders are disorganized, and their living areas are crowded and in disarray. Most collectors can afford to store their items systematically or have enough room to put their collections on display. There have been on occasion collectors who because of their age, mental state, or finances have had their collections fall into a hoarding state.

## Treatment

Many individuals with hoarding disorder do not recognize their hoarding as a problem. In one study, 42% of individuals with hoarding disorder found their behavior problematic compared to the 63% of their family and friends who saw the behavior as problematic. Low insight leads to poor treatment outcomes. Most investigations have found that only a quarter of patients who hoard show an adequate response to these medications and therapeutic interventions.

### Medication

Although no medication has received FDA approval for the treatment of compulsive hoarding, some monoamine reuptake inhibitors (venlafaxine, atomoxetine, paroxetine) have been moderately successful in a small number of low-quality clinical studies. In patients where compulsive hoarding is secondary to or comorbid with frank OCD, serotonergic antidepressants such as SSRIs or the tricyclic antidepressant clomipramine are indicated, although the presence of hoarding predicts relatively poor treatment response. When examined, concurrent pharmacological and psychotherapeutic treatment appeared more effective than either alone.

### Counseling

Cognitive-behavioral therapy (CBT) is a commonly implemented therapeutic intervention for compulsive hoarding. As part of cognitive behavior therapy, the therapist may help the patient to:

* Discover why he or she is compelled to hoard.
* Learn to organize possessions in order to decide what to discard.
* Develop decision-making skills.
* Declutter the home during in-home visits by a therapist or professional organizer.
* Gain and perform relaxation skills.
* Attend family and/or group therapy.
* Be open to trying psychiatric hospitalization if the hoarding is serious.
* Have periodic visits and consultations to keep a healthy lifestyle.

This modality of treatment usually involves exposure and response prevention to situations that cause anxiety and cognitive restructuring of beliefs related to hoarding. Furthermore, research has also shown that certain CBT protocols have been more effective in treatment than others. CBT programs that specifically address the motivation of the sufferer, organization, acquiring new clutter, and removing current clutter from the home have shown promising results. This type of treatment typically involves in-home work with a therapist combined with between-session homework, the completion of which is associated with better treatment outcomes. Research on internet-based CBT treatments for the disorder (where participants have access to educational resources, cognitive strategies, and chat groups) has also shown promising results both in terms of short- and long-term recovery.

Other therapeutic approaches that have been found to be helpful:

1. Motivational interviewing originated in addiction therapy. This method is significantly helpful when used in hoarding cases in which insight is poor and ambivalence to change is marked.
2. Harm reduction rather than symptom reduction. Also borrowed from addiction therapy. The goal is to decrease the harmful implications of the behavior, rather than the hoarding behaviors.
3. Group psychotherapy reduces social isolation and social anxiety and is cost-effective compared to one-on-one intervention. Group CBT tends to have similar outcomes to individual therapy. Although group treatment often does not include home sessions, experimental research suggests that treatment outcomes may be improved if home sessions are included. Individuals have been shown to discard more possessions when in a cluttered environment compared to a tidy environment. Indeed, a meta-analysis found that a greater number of home sessions improves CBT outcomes.

Individuals with hoarding behaviors are often described as having low motivation and poor compliance levels, and as being indecisive and procrastinators, which may frequently lead to premature termination (i.e., dropout) or low response to treatment. Therefore, it was suggested that future treatment approaches, and pharmacotherapy in particular, be directed to address the underlying mechanisms of cognitive impairments demonstrated by individuals with hoarding symptoms.

Mental health professionals frequently express frustration regarding hoarding cases, mostly due to premature termination and poor response to treatment. Patients are frequently described as indecisive, procrastinators, recalcitrant, and as having low or no motivation, which can explain why many interventions fail to accomplish significant results. To overcome this obstacle, some clinicians recommend accompanying individual therapy with home visits to help the clinician:

1. Get a better insight into the hoarding severity and style.
2. Devise a treatment plan that is more suitable to the particular case.
3. Desensitize sufferers to visitors.

Likewise, certain cases are assisted by professional organizers as well.