Condition Header Background

Hoarding Disorder

To understand hoarding, first, we have to talk about the term “clutter”. It describes the burden of many large, unorganized piles of various items consuming large areas of the home. Clutter fills spaces that would normally not be used for storage, such as the floor, furniture, stairs, hallways, or counters.

Hoarding Disorder results when people acquire and resist discarding large quantities of items, and their homes become so cluttered that it impairs their daily life and well-being. People can hoard almost anything imaginable, from newspapers to clothing, food, or even animals. People who hoard place special value on the things they accumulate. What they see as unique or important may look like trash or recyclables to most people. However, hoarding is different from just collecting. While collectors are proud of their possessions and keep them well organized, people who hoard are often ashamed about their affliction and the disorganization it brings to their lives.

This disorganization can even make the home dangerous. Cluttered bathrooms can prevent people from taking care of themselves, and their hygiene and general health will suffer. Clutter in kitchens can impair a regular, healthy diet, and decaying food can attract rodents, ants, and other unsanitary animals, which adds to the unhealthy environment. A cluttered space also prevents regular home maintenance and often leads to broken home heat and water systems going unrepaired.

People who hoard are often reticent to let others into their homes, both because they are embarrassed about their hoarding and because they do not want people to disturb their possessions. As a result, hoarding frequently leads to significant isolation due to the self-seclusion and because family members do not want to live in a cluttered home space. It can also break up families, ending marriages when spouses have had enough.  It may cause custody and visit complications if the courts determine the affected person’s home is not safe for kids.

Causes and Risk Factors

A slow build

Hoarding Disorder occurs in 2-6% of U.S. adults and about 2% of adolescents. The condition is chronic and slowly progressive, often taking decades before coming to a head. Symptoms can start as early as the first teen years, but they don’t start to impair functioning until the mid-20s and most diagnoses are not made until the mid-30s. Severity continues to increase without treatment, and the prevalence in adults over 55 is three times that in adults under 44.

Genes

Though there is no consistent evidence linking Hoarding Disorder to any specific genes, twin studies demonstrate that about 50% of the risk for hoarding is heritable. About 50% of people with Hoarding Disorder have a relative who also hoards.

Early trauma

People with Hoarding Disorder are significantly more likely to report traumatic life events, such as physical and sexual abuse. There is no significant link between being deprived of money, food, or other important goods during childhood. However, these people often report incidents in their youth where someone discarded, without their permission, an object to which they had an emotional connection.

Co-existing disorders

About 75% of people with Hoarding Disorder also have another mood or anxiety disorder. Major Depressive Disorder is the most common, occurring in 50% of people with Hoarding Disorder. This is followed by Social Anxiety Disorder and Generalized Anxiety Disorder, at 23% and 24%, respectively. The inattentive subtype of ADHD occurs in 28% of people with Hoarding Disorder. Obsessive-Compulsive Personality Disorder appeared in 29.5%, while Obsessive-Compulsive Disorder only showed up in 17%.

Diagnosing Hoarding Disorder

Making the diagnosis

People with Hoarding Disorder have great difficulty recycling, selling, or throwing away any possessions even if they have little or no actual value. They believe they need to save items, and they get very anxious when they try to get rid of them. Their homes become so cluttered with their possessions that they can no longer use the living spaces. They simply don’t have space to cook in the kitchen or sleep in their bed. However, this does not include spaces that would normally be cluttered in the average home, like a garage or a basement. Additionally, their possessions can explode beyond their homes and into their yards, vehicles, and even the homes of friends and family. Ultimately, hoarding behavior creates significant problems in work, home, and social lives.

Although hoarding can occur alone, it can also be a symptom of something more, like Obsessive-Compulsive Disorder, Obsessive-Compulsive Personality Disorder, Attention-Deficit/Hyperactivity Disorder, psychotic disorders, or Major Depressive Disorder.

Why hoard?

People often keep items because they think they will need them or that they will become valuable in the future. They have an aversion to wasting things and are resistant to getting rid of objects that were a ‘good deal’ when they were purchased. People’s emotional attachments to objects is a common reason for hoarding. People also hoard sources of information like magazines, newspapers, mail, and paperwork because they believe they will have difficulty remembering information without these objects. Indecision is a common personality trait in people with Hoarding Disorder, which contributes to them having difficulty organizing their possessions and trouble deciding what to keep and what to discard.

Excessive Acquisition

About 80-90% of people with Hoarding Disorder also have “Excessive Acquisition”. They either buy or get for free large numbers of items that they neither need nor have the space to store.

Insight

People with Hoarding Disorder have insight ranging from good, where they understand that their ideas related to hoarding are irrational, to absent/delusional, where they cannot be convinced that their behaviors are unhealthy.

Treating Hoarding Disorder

Cognitive Behavioral Therapy

CBT is the main treatment for Hoarding Disorder. Average symptom severity reduction ranges from 10-30% in group CBT and 27-28% in individual CBT. CBT needs over twice as much time as medication (26 weeks vs 12 weeks) to achieve at least 25% average symptom response.

How CBT for hoarding works

CBT for hoarding is a standardized, manual-based treatment lasting for 26 weekly 1-2 hour sessions that target three aspects of hoarding. People may have attention and decision-making deficits, problematic beliefs regarding importance of their possessions, and emotional grief associated with disposing of or not acquiring objects. The attention problems make organizing possessions difficult, and CBT combats this with decision-making training.

CBT also uses exposure therapy to address the negative emotions associated with disposing of items and positive emotions associated with acquiring new ones. This happens during therapy sessions at the person’s home or at locations where new items may be acquired.

The cognitive techniques of therapy focus on changing the beliefs that people have surrounding their possessions. These include thinking they will possibly need them in the future, not wanting to waste anything, or feeling like they need items to help them remember certain information. They also frequently benefit from Motivational Interviewing, in which therapists guide patients to come to their own conclusions about the benefits of getting treatment for hoarding.

Potential medications

There are no medications approved by the Food and Drug Administration to treat Hoarding Disorder. However, in one study of Effexor (venlafaxine, a selective serotonin and norepinephrine reuptake inhibitor), 70% of people with Hoarding Disorder had a significant reduction in symptom severity. Overall, the medication reduced symptoms by a third. A similar study with Paxil (paroxetine, a selective serotonin reuptake inhibitor) had a smaller effect size, with only 28% gaining a significant reduction in symptom severity.

Managing Hoarding Disorder

Staging an intervention

When a someone has been approached by multiple family members and friends individually about hoarding but continues to be resistant to the idea of treatment, staging an intervention is the next best step. Staging an intervention requires the direction of a professionally trained interventionist. Families and friends use an intervention to convey, in a neutral, nonjudgmental way, how the hoarding has affected them and their relationships with the person. When presented with such a unified front, the person has greater difficulty making excuses for hoarding or diverting the confronter’s attention.

It’s the patient’s choice

All the members of the intervention make it clear that the person must either choose to address the hoarding or face the consequences of having family and friends who are no longer willing to deal with the hoarding. Ultimately, the motivation to get help with hoarding has to come from within, so a good way to approach it is to help the person identify what hoarding prevents them from doing.

Small steps

Starting treatment does not mean that the person has to get rid of everything at once. Instead, it can be done in incremental steps. When friends and family stage an intervention, the goal is usually just to get the person to attend at least one session of therapy, ideally immediately after the intervention. When people with Hoarding Disorder start cleaning, they should start small. Pick a small area of a single room to clean and slowly make progress.

The patient retains control

During treatment, no items will be discarded without the consent. They are the ones who direct the cleaning, no one else. If the cleaning is done against their will, the effort will be in vain because the clutter will recur even more quickly than it first appeared. If the clutter is too overwhelming, enlisting the help of professional cleaning companies that specialize in organizing cluttered homes is one solution.

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References
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