HOARDING DISORDER

Most people have a difficult time NOT acquiring (through purchasing, finding, or being given) a particular item, that appears to have an interest for them, once presented with such an opportunity. In addition, it may also be challenging for many people to discard several of their possessions when needing to do so. Neither of these situations would normally result in a formal "psychiatric" diagnosis. However, 2-6% of the population does, in fact, evidence a clinical diagnosis referred to as Hoarding Disorder (HD), due to the fact that they display significant impairment with respect to the excessive overacquisition of various types of items, and/or a significant difficulty discarding possessions which, for most people, no longer serve any real function in their lives. In fact, people with a diagnosis of Hoarding Disorder may often find it easier to discard a spouse, or contact with their children, in comparison to their tangible possessions. Those who evidence a clinical diagnosis of "Hoarding Disorder", meet the following primary criteria, as outlined within the DSM-V (Diagnostic & Statistical Manual of Mental Disorders):

Individuals who exibit Compulsive Hoarding behaviors display great difficulty resisting the urge to not acquire items across various categories such as paper products (e.g., newspapers, receipts, magazines, etc.); food (e.g., jams, various cooking spices/sauces, several different types of foods themselves); pets (typically cats); clothing; as well as many other types of miscillaneous items including objects found at yard sales, thrift stores, etc.  In addition, once these items have been overacquired, the person with  Hoarding Disorder finds it extremely difficult, often impossible, to disscard nearly any of these possessions.  The major problem caused by this vicious cycle of overacquiring combined with lack of discarding is the extreme "clutter" seen within nearly all of the rooms contained within the person's house or apartment. This degree of clutter makes it nearly impossible for household rooms to be used as intended. That is, due to significant clutter, a kitchen cannot be used to cook or eat in; a bathroom cannot be used to perform basic hygiene tasks; a living room cannot be used for typical activities such as watching TV or entertaaining frinds, etc.  In addition, the degree of clutter may often cause a serious health hazard to those residng within such an environment, such as causing falls resulting in severe medical conditions.

As was mentioned above, those who evidence Hoarding Disorder display great difficulty with both overacquiring, as well as disgarding items. The key issue is, what is the primary reason for these maladaptive behaviors?  The answer seems to involve three primary factors: (1) information processing deficits, (2) the "meaningfulness" which one places on their possessions, and (3) maladaptive "core beliefs" displayed by the person who evidences Hoarding Disorder. With respect to information processing, those with Hoarding Disorder have a tendency to show a bias with respect to the manner in which they attend to certain objects in their immediate surroundings. That is, they tend to over focus on these objects to the extent of paying too much attention to nonessential details concerning the objects themselves, thus making it very difficult to categorize its imporant elements or attributes. Thus, everything about the object appears to some degree of importance, thus making it virtually impossible to order (prioritize) any particular characteristic as being more important than another. This manner of information processesing results in great difficulty with respect to making decisions about whether  to keep or discard any particular possession.  

In addition, those with Hoarding Disorder tend to associate a unique meaningfulness, or value, regarding their possessions. Three types of values take precedence: (a) Instrumental Value, which realtes to the belief that the possession may be of use to this individual, or someone else in the near or distant future. Thus, to discard the object would be a "mistake", as well as representing an "irresponsible" personality characteristic; (b) Sentimental Value, which relates to the degree of emotion associated with a particular possession. For example, the object may not be seen as particularly useful (Instrumental Value), but the deep emotion associated with it, making discarding the possesion nearly impossible; and (c) Instrinsic Value, which relates to the "beauty" of the object itself.  Thus, when these three variables are taken together, the individual with Hoarding Disorder can find a multitude of reasons for keeping nearly all of their possessions..."just in case", they or someone else may one day be able to use the object, or it is simply just too lovely or emotional to discard.

Another addtional factor realted to both the cause and maintenence of Hoarding Disorder concerns the tendency to frequently display several forms of maladaptive cognitive "core beliefs". This type of response pattern has been discussed in another section of this web site, but to briefly summarize, those with Hoarding Disorder have a consistent tendency to overexagerate the degree of responsibility they feel when needing to make a choice concerning the act of either acquiring or discarding a particular object. To not acquire an object, or to discard one, may result in having made a mistake, thus bringing about a feeling of having acted in an irresponable manner.  In addition, another core belief held by those who display Hoarding Disorder deals with the concerpt of "emotional reasoning" (i.e., reasoning that things are the way they are, based on the emotion that one is feeling at that time). When faced with the situation of having to decide if some particular object should be kept, or discarded, should the individual begin to feel sad, ambivilent, guilty, etc., then these feelings may act as the decisive factor to keep the item, as opposed to discarding it. Or, at the very least, to decide to procrastinate such a decision out of fear of making an "irresponsible mistake" (i.e., a "lost opportunity").

The research literature demonstrates that the most effective intervention for Compulsive Hoarding is Cognitive-Behavior Therapy (CBT), with a strong emphasis on Exposure & Response Prevention (ERP). My therapeutic approach depends heavily on the use of Cognitive Therapy treatment strategies which first involve helping the patient to become more aware of, and subsequently change, perceptions and typical interpretations of daily events in their lives (e.g., "if I'm feeling guilty about throwing away this possession of mine, then it would be an irresponsible thing to do"), which create behavioral or emotional discomfort. That is, I first help the patient to better understand their current thought patterns which they frequently use to predict specific outcomes, as well as how these outcomes are often catastrophized. I then help patients to explore other possible interpretations/predictions regarding these outcomes; interpretations that they may not be accustomed to thinking about. In other words, encouraging patients to widen their "perspective lens" by getting into the habit of saying..."wait a minute, is there another way that I can view this situation, a way that is different than my typical manner of explaining to myself why something just happened, or may occur in the near future".

Once this goal has been accomplished, I then begin the Behavior Therapy component of their treatment program for Hoarding Disorder, which incorporates the use of Exposure and Response Prevention (ERP) strategies, while at all times working together with the patient, at his or her own pace. As a result of these goals, it is common to assign weekly out-of-office planned exposure exercises to perform, in addition to various "behavioral experiments", related to either overacquiring an object, or when engaging in the act of discarding or "decluttering" a particular room in his or her home. These exposure sessions help allow for the practice of newly learned skills acquired during each therapy session for the purpose of enhancing and maintaining skills learned within the treatment setting, to the individual’s home and community settings. The basic therapeutic goals are simply this:  If the patient does not want to do something, then they need to do it (declutter); if the patient wants to avoid something, they should face it (attend a garage sale while refraining from making any purchases); if the patient wants to do something to feel better (i.e., acquire an item because to not do so would result in a "missed opportunity"), they should not.

For more information on Compulsive Hoarding, please visit the Obsessive-Compulsive Foundation, The Hoarding Project, and the  Anxiety & Depression Association of America web sites.  In addition, please be sure to review several books and published articles by experts in the field of Hoarding Disorder, such as those written by Dr. Gail Stekette, Dean of the Boston University School of Social Work; and Dr. Randy Frost, Professor of Psychology at Smith College.