Hoarding Help Central’s Guide to Pathological Hoarding

Although compulsive hoarding disorder has long been considered nothing more than a symptom of obsessive-compulsive disorder, we here at Hoarding Help Central know that compulsive hoarding occurs in a variety of illnesses other than obsessive-compulsive disorder. While limited treatment studies have been completed only when compulsive hoarding is a symptom factor of obsessive-compulsive disorder, these studies report that a pharmacological approach as well as multimodal cognitive behavioral therapy can achieve a moderate treatment outcome. That being said, the fact remains that the illness is difficult to treat effectively.

Today, Hoarding Help Central wanted to take the time to explain pathological hoarding. From compulsive hoarding’s relationship with obsessive-compulsive disorder to incidents of hoarding in the elderly population and the best treatment methods available, this guide includes everything you need to know about pathological hoarding. Let’s get started!

What is Compulsive Hoarding Disorder?

According to the American Psychiatric Association, hoarding disorder is defined as a person’s “persistent difficulty getting rid of or parting with possessions, leading to clutter that disrupts their ability to use their living or work spaces”. It should be noted that hoarding is not the same as collecting because, while collectors look for specific items in order to organize or display them, people with hoarding disorder often save random items of little perceived value and store them haphazardly.

Hoarding disorder occurs in an estimated 2 to 6 percent of the adult population and can often lead to problems functioning in everyday life as well as substantial distress. Some research shows that hoarding disorder is more common in males than it is in females and it is also thought to be much more common in older adults- three times as many adults 55 to 94 years are affected by hoarding disorder compared to adults 34 to 44 years old.

With an estimated lifetime prevalence of 4 per 1,000, compulsive hoarding is currently recognized as a severe public health issue where sufferers experience significant comorbidity and morbidity as well as observably impaired neuropsychological functioning. Up until 2013, with compulsive hoarding disorder becoming its own unique disorder in the DSM-V, compulsive hoarding had been coded as one of the eight symptoms of obsessive-compulsive personality disorder rather than a disorder in itself.

Up until this time, compulsive hoarding had been considered a symptom factor of obsessive compulsive disorder although this view had been widely disputed. For this reason, as well as the fact that compulsive hoarding occurs in a wide range of psychiatric disorders other than OCD, prompted the suggestion that it be viewed, rather, as a “multifaceted behavioral phenomenon”.

Compulsive Hoarding and Obsessive-Compulsive Disorder

In total, 10 to 20 percent of all obsessive-compulsive disorder patients have compulsive hoarding as their primary diagnosis with another 42 percent presenting compulsive hoarding as a secondary diagnosis. Some of the defining features of compulsive hoarding include the acquisition and repeated failure to discard possessions regardless of their value, the experiencing of extreme distress and impairment in function, and the prevented use of normal living spaces.

It should be noted that while childhood and early adolescence is the usual period of time in which symptoms begin to pop up, most people only recognize that they have a compulsive hoarding problem later in adulthood. Further, the symptoms outlining excessive clutter and the inability to discard items occur much earlier in life than the active acquisition of items.

Interestingly, compulsive hoarders tend to have a first degree relative that also hoards. This presents the idea that compulsive hoarding likely has genetic roots. Further evidence for a genetic factor in compulsive hoarding behavior is found in the fact that the OCD Collaborative Genetic Study showed a significant linkage to compulsive hoarding on chromosome 14 in families with obsessive-compulsive disorder where there were two or more hoarders present. Further, there was a significant linkage found on chromosome 3 for families with fewer than two or more hoarding relatives.

Phenomenology

It should be noted that compulsive hoarders acquire many more items than non hoarders. While the items may be similar, acquisitions often include multiples of identical items. Acquisition most often occurs through purchasing, stealing, the pursuit of “freebies”, or a combination of each of the strategies. For some compulsive hoarders, persistent acquisition results in extreme debt, the depletion of personal and family savings, and theft. Some of the most common items hoarded by compulsive hoarders include books, clothes, magazines, toiletries, containers, mechanical parts, newspapers, notes or lists, and receipts.

Compulsive hoarders can be considered handicapped in their ability to discard. This likely stems from an intense set of beliefs about the value of their possessions whether it be in use, safety, or sentimental value. Hoarders value their items highly and this can be for a multitude of different reasons. For one, hoarders may believe that their items hold intense future value. A compulsive hoarder may also believe that their items are “friends” or may view the act of discarding the items as wastefulness.

While the act of hoarding is often organized at the start, eventually the act of hoarding becomes much less organized as the volume of items increases. Soon, both living and nonliving areas become overwhelmed with clutter and this makes it hard for the occupants of the home to use these areas normally. Psychosocial morbidity is higher in compulsive hoarders than it is in OCD non hoarders. Many compulsive hoarders will never marry, 50 percent of compulsive hoarders are unemployed, and family conflict is increasingly common. Hoarders also tend to isolate themselves as they are embarrassed about their situation and, for this reason, avoid visitors and live an isolated existence.

Comorbidity and Compulsive Hoarding

With 92 percent of compulsive hoarders having one additional psychiatric diagnosis, that of which typically includes major depression, bipolar disorder, panic disorder, substance abuse, social phobia, or generalized anxiety disorder, those who hoard compulsively have much more comorbidity than OCD non hoarders. It should also be noted that females have greater comorbidity than their male counterparts.

How is Compulsive Hoarding Disorder Diagnosed?

Due to the fact that compulsive hoarders are often secretive and embarrassed about their situation, hoarders are often reluctant about seeking treatment. Still, clinical experience shows that, upon being asked about their compulsive hoarding problem, most hoarders experience some relief in being asked about their condition. A number of questions can prove helpful in diagnosing compulsive hoarding disorder, including:

• Do you acquire multiple items that have little value?
• Do you have difficulty resisting the urge to acquire possessions even though you will likely never use them?
• How often do you actively avoid discarding possessions?
• Is the act of discarding possessions stressful for you?
• How much of your home is cluttered by your possessions?
• Are you reluctant to have people over to your home because of the clutter?
• Does the state of your home cause you to feel embarrassed?
• What do your possessions mean to you?
• Are sections of your home unable to be used due to the clutter?

Further, to officially be diagnosed with compulsive hoarding disorder, a person must meet the DSM-V’s criteria for compulsive hoarding disorder which contain the following:

1. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
2. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
3. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).
4. The hoarding causes 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 is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).
6. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

Treatment Methods for Compulsive Hoarding Disorder

So how can compulsive hoarding disorder be treated? While the results for each of the primary methods used to treat compulsive hoarding disorder vary, the two best approaches seem to be pharmacotherapy and cognitive behavioral therapy.

Compulsive hoarding has historically been considered to respond poorly to pharmacological strategies used in treating obsessive-compulsive disorder. In the only treatment study that specifically evaluated the treatment response of a specific serotonin reuptake inhibitor (SSRI) on compulsive hoarding, 20–60 mg paroxetine over 10–12 weeks resulted in 50% of subjects having either a partial or full response.

In limited studies done on the subject, a multimodal approach to cognitive behavioral therapy has been reported to be effective in treating compulsive hoarding disorder. Multimodal treatment focuses on emphasizing a focus on psychoeducation while simultaneously addressing the cognitive deficits that underlie compulsive hoarding disorder. In this approach, strategies that inhibit acquisition are encouraged using response prevention techniques. Discarding items is promoted and, in cognitive behavioral therapy, the hoarder is encouraged to accept that distress, and not harm, will accompany this act.

Understanding Equals Better Intervention

At Hoarding Help Central, we believe that a better understanding of pathological hoarding equals better intervention strategies. When you are able to better understand all of the facets of compulsive hoarding disorder, you will be better equipped to handle the undertaking that is assisting someone with the disorder. Take this information into account when formulating effective intervention strategies!