Hoarding disorder

Hoarding disorder
Other namesCompulsive hoarding
Compulsive hoarding in an apartment
SpecialtyPsychiatry, clinical psychology
SymptomsExcessive acquisition, Perceived need to save possessions, Persistent difficulty discarding or parting with possessions, regardless of their actual value, Intense urge to keep items and distress when getting rid of them.
Usual onsetAges 11–15[1]
DurationChronic[2]
CausesNot clear, possibly genetic, and stressful life experiences[1]
Risk factorsTraumatic events[3]
Diagnostic methodICD-10-CM Code F42.3, DSM-5 300.3 (F42)
TreatmentPsychotherapy[4]
PrognosisProgressive[2]
FrequencyUK: 2–5% of population
US: Up to 6%[5]
GER: c. 1.8 million[6]

Hoarding disorder (HD) or Plyushkin's disorder, is a mental disorder[7] characterised by persistent difficulty in parting with possessions and engaging in excessive acquisition of items that are not needed or for which no space is available. This results in severely cluttered living spaces, distress, and impairment in personal, family, social, educational, occupational, or other important areas of functioning.[7][8] Excessive acquisition is characterized by repetitive urges or behaviours related to amassing or buying property. Difficulty discarding possessions is characterized by a perceived need to save items and distress associated with discarding them. Accumulation of possessions results in living spaces becoming cluttered to the point that their use or safety is compromised.[9] It is recognised by the eleventh revision of the International Classification of Diseases (ICD-11)[10][11] and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).[12]

Prevalence rates are estimated at 2% to 5% in adults,[13] 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.[14]

People with hoarding disorder commonly live with other complex and/or psychological disorders such as depression,[15] anxiety, obsessive compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD).[16] Other factors often associated with hoarding include alcohol dependence and paranoid, schizotypal and avoidance traits.[17]

Diagnosis

Collecting and hoarding may seem similar, but there are distinct characteristics that set the behaviors apart. Collecting is a hobby often involving 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, typically appears haphazard and involves the overall acquiring of common items that would not be especially meaningful to the person who is gathering such items in large quantities.[18][19] 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 to have enough room to display their collections.[20] Age, mental state, or finances have caused some collectors to fall into a hoarding state.[21]

The Clutter Image Rating

Hoarders may pile their belongings in their homes, yards, or garages. This garage has been converted into an additional room, and demonstrates clutter, with a large number of objects of various sizes being haphazardly spread throughout the space. Exactly what constitutes a room or space as being cluttered varies from person to person.

A UK charity called HoardingUK, has found that people have very different ideas about what it means to have a cluttered home. For some, a small pile of things in the corner of an otherwise well-ordered room constitutes serious clutter. For others, only when the narrow pathways make it hard to get through a room does the clutter register. To ensure an accurate sense of a clutter problem and encourage people to get support, Hoarding UK uses the Clutter Image Rating, created by R. O. Frost and G. Steketee, a series of pictures of rooms in various stages of clutter – from completely clutter-free to very severely cluttered.[22]

Epidemiology

The prevalence of hoarding disorder is estimated to be between 2 and 6 percent, although some surveys indicate the lifetime prevalence may be as high as 14%.[23] First-degree relatives of those with hoarding disorder are significantly more likely to report hoarding symptoms, and hoarding likely comes about due to a combination of genetic and environmental factors.[23]

Rates of hoarding increase significantly with age, and people over the age of 54 are three times as likely to meet criteria for hoarding disorder. However, hoarding symptoms typically manifest in early childhood, and worsen to the point of becoming clinically significant during middle age. Over half of hoarders report the onset of hoarding as being associated with a traumatic life event, and in this portion of hoarders, the age of onset is much higher. Epidemiological studies have found that hoarding is twice as common in males, although clinical studies on hoarding tend to be predominantly female, suggesting that male hoarders are a significantly understudied and under-treated population.[23]

Hoarding is a significant problem around the world and can post a public health risk when hoarding escalates enough to damage the integrity of a structure or attract vermin. Accumulated items can block exits during fires and increase the risk of injury. In Japan, hoarder houses are known as "garbage mansions" (ごみ屋敷, gomi yashiki), and have become a topic of public alarm in Japanese mass media.[24] In the Eastern United states, they are sometimes called Collyer mansions or Collyers, after the infamous Collyer brothers.

Comorbidity

Under the DSM-IV, hoarding was listed as a symptom of obsessive–compulsive personality disorder and obsessive–compulsive disorder; however, hoarding was found to have a relatively weak connection to OCD or OCPD compared to their other symptoms. Due to this evidence, hoarding disorder was separated as its own disorder in the DSM-5.[23] However, hoarding does frequently co-occur with OCD. OCD patients with hoarding symptoms were found to display a distinct form of hoarding in which they were more likely to hoard "bizarre items" and perform compulsive rituals associated with their hoarding behavior, such as rituals around checking items or rituals to be performed before discarding them.[25]

However, the majority of hoarders do not show OCD symptoms. Hoarding has been found to be correlated with depression, social anxiety, compulsive grooming disorders such as trichotillomania, bipolar disorder, reduced cognitive and affective empathy[26] and compulsive shopping.[23][27][28] Hoarders have higher than average rates of traumatic past events, particularly those associated with loss or deprivation. Past events which occurred before the onset of hoarding are correlated to a subject's emotional attachment to physical objects, and past events after the onset of hoarding increase a subject's anxiety around memory.[29] Hoarders are also more likely to have a past with alcohol abuse.[23]

The prevalence of different comorbidities is influenced by gender. In men, hoarding is associated with generalized anxiety disorder and tics, while among women, hoarding is associated with social phobia, post-traumatic stress disorder, body dysmorphic disorder, and compulsive grooming behaviors like nail-biting and skin-picking.[23]

Studies

In a 2010 study using data from self-reports of hoarding behavior from 751 participants, it was found 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 showed 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 effects of family presence earlier in life and limits on hoarding imposed by housing situation and lifestyle. The understanding of early onset hoarding behavior may help in the future to better distinguish hoarding behavior from "normal" childhood collecting behaviors.[30]

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 an 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 sexual 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 the severity of their hoarding symptoms from 1 to 4, 4 being the most severe. 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.[30]

Although excessive acquiring is not a diagnostic criterion of hoarding, at least two-thirds of individuals with hoarding disorder excessively acquire possessions.[28] 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.[31] Anthropomorphism has been shown to increase both the sentimental value and perceived utility of items.[32] 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. Individuals with hoarding problems have been shown to have greater interpersonal problems than individuals who only excessively acquire possessions,[33] which provides some support for the assumption that individuals with hoarding problems may have a stronger motivation to hang onto possessions for support. As possessions cannot provide support in the way humans can and because saving excessively can frustrate other people due to its impact on their quality of life, individuals with hoarding disorder may be caught in a feedback loop. They may save to alleviate distress, but this saving may cause distress, which may lead them to keep saving to alleviate the distress.

Treatment

Only 5% of people with hoarding behaviours receive help (Singh, 2012) and the interventions they do receive focus on clearing items, not treating the disorder.

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 one 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.[34]

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 affected person, 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.[35] 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.[36]

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.[37][38]
  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.[38]
  3. Group psychotherapy reduces social isolation and social anxiety and is cost-effective compared to one-on-one intervention.[39] Group CBT tends to have similar outcomes to individual therapy.[40] 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.[41] Indeed, a meta-analysis found that a greater number of home sessions improves CBT outcomes.[42]

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.[39][43] 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.[44]

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,[39][43] 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 affected patients to visitors.[45]

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

  • Maguire, Emily: Love Objects (2021), Allen & Unwin, ISBN 9781760878337[46]
  • Hoarders - TV series
  • Hoarding: Buried Alive
  • Britain's Biggest Hoarders
  • The Hoarders Next Door
  • Hoarders SOS
  • Clean House
  • Clutter Nutters
  • How Clean Is Your House?
  • Confessions: Animal Hoarding
  • Hoarders: Canada
  • Hoarded House Flippers

See also

Hoarders

  • Alexander Kennedy Miller, hoarded about 30 Stutz automobiles (1906–1993)
  • Collyer brothers, Homer Collyer (1881–1947) and Langley Collyer (1885–1947)
  • Edmund Trebus (1918–2002), participated in TV documentary
  • Edith Bouvier Beale and Edith Ewing Bouvier Beale, American socialites featured in the 1975 documentary Grey Gardens

References

  1. 1 2 "Hoarding disorder – Symptoms and causes". Mayo Clinic. Retrieved 17 March 2019.
  2. 1 2 Grisham JR, Frost RO, Steketee G, Kim HJ, Hood S (2006). "Age of onset of compulsive hoarding". Journal of Anxiety Disorders. 20 (5): 675–686. doi:10.1016/j.janxdis.2005.07.004. PMID 16112837.
  3. ↑ Cromer KR, Schmidt NB, Murphy DL (November 2007). "Do traumatic events influence the clinical expression of compulsive hoarding?". Behaviour Research and Therapy. 45 (11): 2581–2592. doi:10.1016/j.brat.2007.06.005. PMID 17673166.
  4. ↑ "Hoarding disorder – Diagnosis and treatment – Mayo Clinic". www.mayoclinic.org.
  5. ↑ Solovitch S (April 11, 2016). "Hoarding is a serious disorder – and it's only getting worse in the U.S." The Washington Post. Retrieved 17 March 2019.
  6. ↑ "Messie-Syndrom: Löcher in der Seele stopfen". September 2002. Retrieved 27 May 2022.
  7. 1 2 Sun, Lena H. (2023-05-18). "Updates to psychiatry's guidebook change criteria for ADHD, autism". Washington Post. ISSN 0190-8286. Retrieved 2023-09-18.
  8. ↑ "US mental health 'bible' DSM-5 updated". BBC News. 2013-05-17. Retrieved 2023-09-18.
  9. ↑ "Clinical Classification of Hoarding Disorder | OCD-UK". Retrieved 2021-10-01.
  10. ↑ Ng, Huiwen (2019-05-28). "'Doctor, I can't stop playing video games': 6 things about WHO's latest catalogue for diagnosing medical conditions worldwide". The Straits Times. ISSN 0585-3923. Retrieved 2023-09-19.
  11. ↑ Fontenelle, Leonardo F.; Grant, Jon E. (2014). "Hoarding disorder: a new diagnostic category in ICD-11?". Revista Brasileira De Psiquiatria (Sao Paulo, Brazil: 1999). 36 Suppl 1: 28–39. doi:10.1590/1516-4446-2013-1269. ISSN 1809-452X. PMID 25388610.
  12. ↑ American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders. doi:10.1176/appi.books.9780890425787. ISBN 978-0-89042-575-6. S2CID 249488050. Retrieved 2023-09-09 – via DSM Library.
  13. ↑ Pertusa A, Frost RO, Fullana MA, Samuels J, Steketee G, Tolin D, et al. (June 2010). "Refining the diagnostic boundaries of compulsive hoarding: a critical review". Clinical Psychology Review. 30 (4): 371–386. doi:10.1016/j.cpr.2010.01.007. PMID 20189280.
  14. ↑ Ayers CR, Saxena S, Golshan S, Wetherell JL (February 2010). "Age at onset and clinical features of late life compulsive hoarding". International Journal of Geriatric Psychiatry. 25 (2): 142–149. doi:10.1002/gps.2310. PMC 4083761. PMID 19548272.
  15. ↑ Kancherla N, Garlapati SK, Sowkhya P, Yegateela T, McCrary A (June 2022). "A Case of Coexisting Depression and Hoarding Disorder". Cureus. 14 (6): e25645. doi:10.7759/cureus.25645. PMC 9249064. PMID 35784984.
  16. ↑ "Hoarding Definition – Diseases and Conditions". Mayo Clinic. 2011-05-25. Archived from the original on 2013-10-24. Retrieved 2014-05-01.
  17. ↑ Samuels JF, Bienvenu OJ, Grados MA, Cullen B, Riddle MA, Liang KY, et al. (July 2008). "Prevalence and correlates of hoarding behavior in a community-based sample". Behaviour Research and Therapy. 46 (7): 836–844. doi:10.1016/j.brat.2008.04.004. PMC 2483957. PMID 18495084.
  18. ↑ "Hoarding Disorder". American Psychiatric Association. Archived from the original on 2014-10-23. Retrieved 2014-10-30.
  19. ↑ Neziroglu F. "Hoarding: The Basics". ADAA. Archived from the original on October 31, 2014. Retrieved October 30, 2014.
  20. ↑ "Hoarding Disorder". psychiarty.org. American Psychiatric Association. Archived from the original on 21 December 2014. Retrieved 11 December 2014.
  21. ↑ "Fabulous 60 car stash found in French barn". onlymotors.com. 2014-12-05. Archived from the original on 2015-06-11.
  22. ↑ "Clutter Image Rating" (PDF). πhoardinguk.org. Retrieved August 13, 2022.
  23. 1 2 3 4 5 6 7 Grisham JR, Norberg MM (2010-06-30). "Compulsive hoarding: current controversies and new directions". Dialogues in Clinical Neuroscience. 12 (2): 233–240. doi:10.31887/DCNS.2010.12.2/jgrisham. PMC 3181962. PMID 20623927.
  24. ↑ Kuwano M, Nakao T, Yonemoto K, Yamada S, Murayama K, Okada K, et al. (March 2020). "Clinical characteristics of hoarding disorder in Japanese patients". Heliyon. 6 (3): e03527. Bibcode:2020Heliy...603527K. doi:10.1016/j.heliyon.2020.e03527. PMC 7063155. PMID 32181397.
  25. ↑ Pertusa A, Fullana MA, Singh S, Alonso P, Menchón JM, Mataix-Cols D (October 2008). "Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both?". The American Journal of Psychiatry. 165 (10): 1289–1298. doi:10.1176/appi.ajp.2008.07111730. PMID 18483134.
  26. ↑ Chen, Wenting; McDonald, Skye; Wearne, Travis; Grisham, Jessica (June 2021). "Investigating associations between hoarding symptoms and affective and cognitive empathy". The British Journal of Clinical Psychology. 60 (2): 177–193. doi:10.1111/bjc.12280. ISSN 0144-6657. PMID 33587764.
  27. ↑ Abramowitz JS, Wheaton MG, Storch EA (September 2008). "The status of hoarding as a symptom of obsessive-compulsive disorder". Behaviour Research and Therapy. 46 (9): 1026–1033. doi:10.1016/j.brat.2008.05.006. PMID 18684434.
  28. 1 2 Frost RO, Steketee G, Tolin DF (October 2011). "Comorbidity in hoarding disorder". Depression and Anxiety. 28 (10): 876–884. doi:10.1002/da.20861. PMC 3188689. PMID 21770000.
  29. ↑ Fontenelle LF, Muhlbauer JE, Albertella L, Eppingstall J (2021-01-01). "Traumatic and stressful life events in hoarding: the role of loss and deprivation". European Journal of Psychotraumatology. 12 (1): 1947002. doi:10.1080/20008198.2021.1947002. PMC 8312593. PMID 34367527.
  30. 1 2 Tolin DF, Meunier SA, Frost RO, Steketee G (September 2010). "Course of compulsive hoarding and its relationship to life events". Depression and Anxiety. 27 (9): 829–838. doi:10.1002/da.20684. PMID 20336803. S2CID 429636.
  31. ↑ Norberg MM, Crone C, Kwok C, Grisham JR (March 2018). "Anxious attachment and excessive acquisition: The mediating roles of anthropomorphism and distress intolerance". Journal of Behavioral Addictions. 7 (1): 171–180. doi:10.1556/2006.7.2018.08. PMC 6035017. PMID 29444605.
  32. ↑ Kwok C, Grisham JR, Norberg MM (December 2018). "Object attachment: Humanness increases sentimental and instrumental values". Journal of Behavioral Addictions. 7 (4): 1132–1142. doi:10.1556/2006.7.2018.98. PMC 6376393. PMID 30311771.
  33. ↑ Norberg MM, Kwok C, Crone C, David J, Kakar V, Grisham JR (2020). "Greater interpersonal problems differentiate those who excessively acquire and save from those who only excessively acquire possessions". Journal of Obsessive-Compulsive and Related Disorders. 27: 100571. doi:10.1016/j.jocrd.2020.100571. S2CID 225342060.
  34. ↑ Roger, Harms W. "Definition". Mayo Clinic. Mayo Foundation for Medical Education and Research, 25 May 2011. Web. 21 Mar. 2012.
  35. ↑ Tolin DF, Frost RO, Steketee G (July 2007). "An open trial of cognitive-behavioral therapy for compulsive hoarding". Behaviour Research and Therapy. 45 (7): 1461–1470. doi:10.1016/j.brat.2007.01.001. PMC 1950337. PMID 17306221.
  36. ↑ Muroff J, Steketee G, Himle J, Frost R (January 2010). "Delivery of internet treatment for compulsive hoarding (D.I.T.C.H.)". Behaviour Research and Therapy. 48 (1): 79–85. doi:10.1016/j.brat.2009.09.006. PMID 19800051.
  37. ↑ Gilliam CM, Tolin DF (2010). "Compulsive hoarding". Bulletin of the Menninger Clinic. 74 (2): 93–121. doi:10.1521/bumc.2010.74.2.93. PMID 20545491.
  38. 1 2 Tolin DF (May 2011). "Challenges and advances in treating hoarding". Journal of Clinical Psychology. 67 (5): 451–455. doi:10.1002/jclp.20796. PMID 21374598.
  39. 1 2 3 Frost RO (February 2010). "Treatment of hoarding". Expert Review of Neurotherapeutics. 10 (2): 251–261. doi:10.1586/ern.09.159. PMID 20136381. S2CID 21169686.
  40. ↑ Gilliam CM, Norberg MM, Villavicencio A, Morrison S, Hannan SE, Tolin DF (November 2011). "Group cognitive-behavioral therapy for hoarding disorder: an open trial". Behaviour Research and Therapy. 49 (11): 802–807. doi:10.1016/j.brat.2011.08.008. PMID 21925643.
  41. ↑ Crone C, Norberg MM (August 2018). "Scared and surrounded by clutter: The influence of emotional reactivity". Journal of Affective Disorders. 235: 285–292. doi:10.1016/j.jad.2018.04.066. PMID 29660644. S2CID 4945691.
  42. ↑ Tolin DF, Frost RO, Steketee G, Muroff J (March 2015). "Cognitive behavioral therapy for hoarding disorder: a meta-analysis". Depression and Anxiety. 32 (3): 158–166. doi:10.1002/da.22327. PMID 25639467. S2CID 205736485.
  43. 1 2 Tolin DF (May 2011). "Understanding and treating hoarding: a biopsychosocial perspective". Journal of Clinical Psychology. 67 (5): 517–526. doi:10.1002/jclp.20795. PMID 21360705.
  44. ↑ Saxena S (May 2011). "Pharmacotherapy of compulsive hoarding". Journal of Clinical Psychology. 67 (5): 477–484. doi:10.1002/jclp.20792. PMID 21404273.
  45. ↑ Frost RO, Hristova V (May 2011). "Assessment of hoarding". Journal of Clinical Psychology. 67 (5): 456–466. doi:10.1002/jclp.20790. PMID 21351103.
  46. ↑ Baum C (1 April 2021). "As we stockpile wealth, toilet paper, novelist gives voice to a 'hoarder'". The Sydney Morning Herald.

Further reading

  • Frost RO, Steketee G (2011). Stuff: Compulsive Hoarding and the Meaning of Things. Mariner Books. ISBN 9780547487250.
  • Herring S (2014). The Hoarders: Material Deviance in Modern American Culture. Chicago: University of Chicago Press. ISBN 9780226171715.
  • Mapes D (11 March 2008). "Engulfed in Clutter, Hoarders Keep Heaping It On". NBC News. Archived from the original on 8 May 2019. Article discussing the disorder and its relationship to OCD.
  • Sholl J (2010). Dirty Secret: A Daughter Comes Clean About Her Mother's Compulsive Hoarding. New York: Simon & Schuster/Gallery Books. ISBN 9781439192535.
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