Hoarding Disorder: A Fine Line Between Collecting and Saving
In today’s world, mental health has become a huge topic on television. Whether it’s documentary style or fiction, we as viewers trust that the media’s take on psychology-related topics and issues are accurate. After all, it’s Hollywood. But don’t let such reality and fictitious programs fool you. Reality shows like Hoarding: Buried Alive and Hoarders have become part of today’s mass media, created to entertain and shock their viewing audiences. In the end, entering someone’s home unannounced, with a production and cleaning crew, and pressuring people to discard their possessions is probably not the best way to help someone overcome their hoarding disorder. So, what is the best way of helping someone with Hoarding Disorder? In this article, you will become familiar with the scientific definition of hoarding disorder, DSM-5 criteria, the prevalence of hoarding disorder, signs and symptoms, treatment, comorbidity, and 8 self-help tips.
What is Hoarding Disorder?
Hoarding disorder, or better known as HD, is characterized by the acquisition of, and inability to discard possessions to a degree that precludes the appropriate use of living spaces and that creates significant distress or impairment in functioning. Hoarding disorder is a crippling mental ailment associated with an extensive variety of neurocognitive variations that deviate from the norm.
Frost and Hartl proposed the first systematic definition and diagnostic criteria for compulsive hoarding disorder. The following criterion appears to have clinical significance in a medical and psychological treatment effect in those with hoarding disorder:
- The acquisition of and failure to discard a large number of possessions that appear (to others) to be useless or of limited value.
- Living or workspaces are sufficiently cluttered so as to preclude activities for which those spaces were designed.
- Significant distress or impairment in functioning is caused by the hoarding behavior or clutter.
This clinical framework provides a solid foundation for the development and testing of research hypotheses surrounding this newly independent and multifaceted disorder.
Hoarding Disorder and the DSM-5
The diagnostic criteria for hoarding disorder has been found to have astounding affectability, specificity, reliability, and legitimacy. A few elements have affected the DSM– 5’s arrangement of hoarding disorder. For example, there has been quite a bit of evidence showing that people with hoarding disorder have neurocognitive shortfalls and that the pattern of their deficits varies from that found in patients with obsessive-compulsive disorder. In spite of the fact that hoarding disorder has been perceived as an autonomous diagnostic category, hoarding symptoms can occur in several neurological and psychiatric conditions, including OCD, schizophrenia, and major depressive disorder.
As stated in the DSM-5, an individual with hoarding disorder finds:
A) Persistent difficulty discarding or parting with possessions, regardless of their actual value.
B) A perceived need to save the items and the distress associated with discarding them.
C) The accumulation of possessions that congest and clutter active living areas which substantially compromises their intended use. With the help of third-party interventions (e.g., family members, cleaners, authorities), the individual may see eye to eye on this issue and agree to declutter their living spaces.
D) Clinically significant distress or impairment in social, occupational, or other important areas of functioning that endangers the safety of every individual living in the space.
E) Hoarding is not attributable to another medical condition (e.g., traumatic brain injury, dementia, cerebrovascular disease) or
F) 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). A hoarding disorder determination requires the underwriting of every one of these six criteria in the DSM-5.
In past releases of the DSM, hoarding behaviors were formally perceived just as an indication of an obsessive-compulsive personality. Keeping up its association with obsessive-compulsive highlights, yet making an interesting identity, hoarding disorder is, at present, ordered under the Obsessive-Compulsive and Related Disorders area of the DSM-5.
Prevalence of Hoarding Disorder
Hoarding disorder is estimated to be prevalent in around 2 to 6% of the general U.S. population. However, a national epidemiological investigation has not been directed to affirm the true prevalence of this disorder. Factors such as embarrassment and a lack of insight related to the severity of the behaviors may confound prevalence estimates. Hoarding disorder is found to be more pervasive in ages 55– 94 years old, yet some later investigations have reported that the initial onset of the disorder often occurs in childhood and adolescence.
Prevalence of Hoarding Disorder in Children
In young children, both collecting and storing behaviors are common and developmentally normal. Collecting and storing behaviors increase linearly in frequency from age 2 to around age 6, when roughly 60% of youngsters display such behaviors. Hoarding behaviors supposedly diminish between ages 6 to 8. As much as there are few genuine epidemiological investigations of clinically assessed hoarding disorders in kids, population-based examinations recommend that almost 10% of children, ages 6 to 17, have at least moderate levels of hoarding behaviors, while approximately 3% have abnormal amounts of hoarding. In typically developing children, it is vital to separate conceivable obsessive or hazardous hoarding side effects, (for example, tenacious hoarding of trash or food) from age-fitting behaviors. A child who finds it difficult to dispose of their collection of plush toys would not be considered hoarding.
Prevalence of Hoarding Disorder in Adolescence
The rates of clinically significant hoarding behaviors in adolescence were analyzed in a populace based cross section of 15-year-old twins. Homologous to DSM-5 criteria, clinically significant hoarding was depicted as an event where severe side effects identified with clutter, trouble disposing of the clutter, and related distress or impairment during the discarding process. Results demonstrated a prevalence of approximately 2% (increasing to 3.7% when the clutter criterion was eliminated).
Prevalence of Hoarding Disorder in Young Adults
These investigations lead to the belief that non-impairing hoarding, storing, and/or collecting behaviors may continue at stable, moderate rates (up to 10%) throughout childhood, while rates of clinically impairing hoarding behaviors, that are analogous to hoarding disorder, approximate those seen in early adulthood. Significantly higher rates of clinically disabling hoarding behaviors have been accounted for in children with obsessive-compulsive disorder (OCD) or large amounts of OC side effects, Prader-Willi syndrome, autism, intellectual or developmental disabilities, and learning disabilities. Retrospective studies suggest that the overall prevalence of hoarding disorder in adults is between 2% and 6%, and the age of onset of hoarding symptoms is typically between age 11 and 15. hoarding disorder rates have all the earmarks of being moderately equivalent between the genders, although there is some evidence that women demonstrate more excessive acquisition. The rate of hoarding disorder in adults ascends with increasing age, from 1% to 2% at age 20 to more than 7% among individuals ages 70 or older. The greatest rates of increase are found in those between the ages of 35 and 65
Increased rates of prevalence throughout the lifespan reflect age-related ecological components. For instance, parents of children and adolescents are more likely to limit their hoarding behaviors, thus minimizing the severity and impact of their hoarding disorder. Adults may have more control over their surroundings and therefore fewer external limitations on the accumulation of clutter. Additionally, roommates, spouses, or other family members are responsible for the increased clinical impairment in older adults due to their imposition of external control over the accumulation of clutter.
Signs and Symptoms of Hoarding Disorder
Hoarding and saving symptoms are the two most important pieces of this discrete clinical disorder. Included in the core symptoms of difficulty in discarding, urges to save, excessive acquisition and clutter, a psychological measure of hoarding disorder highlights the related psychological symptoms of indecisiveness, perfectionism, procrastination, disorganization, and avoidance. Given that hoarding disorder has recently been recognized as a distinct disorder, habitual hoarding behaviors have been formally recognized in the counseling literature for more than 2 decades. Left untreated, the seriousness of symptoms will likely increase with every decade that passes. Though the average age of those seeking treatment for hoarding disorder is 50 years of age, symptoms become more clinically significant with age. The effects of the hoarding often escalate because of the acquisition of possessions that occur over time.
Individuals who suffer from hoarding disorder show these basic signs and symptoms:
- A false and rationally unsupported belief that the possessions that are being accumulated are necessary to keep. The rationale for hoarding behaviors frequently revolves around the perceived potential usefulness or value of items in the future.
- An emotional attachment to objects. Emotions are often positive reinforcers of their behavior which strengthens favorable outcomes that will most likely occur again in the future.
- A need to keep objects to “aid memory”. An individual with hoarding disorder associates animate and inanimate objects with personal memories and past experiences. Without these objects, they fear that they won’t be able to reminisce or remember memories.
- Distress associated with having to discard items. An individual may feel anguish when they have to destroy their emotional attachment to the object.
- An urge to acquire and save objects. Popular hoarding items include daily papers, coffee cups, statues, home decor, and collectibles.
- A marked inability to discard objects that may have no apparent value to others. Items that appear to have no apparent value to others hold significant sentimental value to them.
- Excessive clutter in daily living spaces that results in limited functioning.
- Individuals do not discriminate among the items collected and acquired. More than half of all individuals with hoarding disorder hoard both inanimate (newspapers) and animate (animals) objects.
Hoarding Disorder: Signs and Symptoms of Excessive Acquisition
Excessive acquisition might be identified with superfluous buying, purchasing additional items in the event that something goes wrong, collecting free things, or obtaining items through stealing. Women were more likely to report excessive buying, whereas men were more likely to report collecting free items and stealing. This might be because of the increased control over financial assets and living spaces that accompanies adulthood.
Hoarding Disorder: Signs and Symptoms In Early Childhood
Hoarding disorder often presents early in the lifespan; one study found that 80% of participants reported a childhood onset of symptoms. Hoarding behaviors are often less pronounced and cause mild impairments due to parental involvement in the counteractive action of clutter accumulation in living spaces. The disposition of hoarding in youth regularly includes a moderate connection to inanimate objects, such as stuffed animals, and an assignment of human qualities to such objects. These experiences must be distinct from age-appropriate behavior and involve the additional symptoms of hoarding disorder in order to be seen as early- childhood onset.
Hoarding Disorder: Signs and Symptoms of Animal Hoarding
Animal hoarding involves the acquisition of a large number of animals, restriction to one animal group, and is typically associated with poorer insight and a greater severity of dysfunction. People who take part in this specific subset of hoarding disorder attempt to justify their behaviors by citing an obligation to care for animals. In reality, their “care” does more harm than good. An unhealthy environment for both the individual and the animals result in malnutrition, an unintentional disregard for the animals, and exposure to harmful bacteria in the home and surrounding environments. Excessive acquisition will most likely co-occur with animal hoarding. McGuire found that albeit 47% of those who hoarded objects did not hoard animals, only 2% of those who hoarded animals did not hoard objects. Limited insight into the harmful effects of animal hoarding prevents them from seeking veterinary care for sick animals, and even from removing the bodies of dead animals from their homes. Currently, analysts conceptualize animal hoarding as a subtype of hoarding disorder that meets the current demonstrative criteria in the DSM-5.
Several papers have focused on early- onset compulsive hoarding and hoarding symptoms in subjects with OCD but what about the age of onset and progression of hoarding symptoms in older adults? An older adult sample would provide particularly important retrospective information on symptom trajectory across the life course.
See the “read further” section below for information on the early and late onset of hoarding disorder.
Hoarding Disorder Statistics
Gender and Hoarding Disorder
The interaction between time, demographic variables (gender, education, ethnicity, family), and reported hoarding symptoms predicts reported hoarding symptoms separately. A mixed effect analysis offers deep insight into the course of hoarding disorder throughout the lifespan in older adults who meet DSM- 5 criteria.
Men show higher clutter symptoms than women but the difference between gender and difficulty discarding or saving objects is unnoted. The interaction between gender and all hoarding symptoms is significant in that men’s reported symptoms increase more slowly than those of women across time. Gender differences, in the progression of hoarding, may exist such that women recall having experienced a steeper increase in hoarding severity over the lifespan. In the reported age of onset, clutter is the only symptom to demonstrate gender differences in hoarding severity. Women may have few clutter symptoms early in life, but this does not seem to impact clutter levels in older adulthood.
These results show that gender disparities prevail in adults who seek treatment. More women than men seek out treatment and are more open to the idea of participating in hoarding studies. This suggests that gender may factor into symptom presentation.
Education and Hoarding Disorder
Years of education did not have an effect on any of the hoarding symptoms. However, there was a significant education by time interaction effect for saving such that individuals with higher levels of education reported a slower rate of increase for saving symptoms than did individuals with lower levels of education.
Ethnicity and Hoarding Disorder
As far as ethnicity, there was no main effect for ethnicity and no ethnicity by time interaction for any of the hoarding symptoms.
Family History and Hoarding Disorder
Having one parent with hoarding tendencies had a significant main effect for all hoarding symptoms. Individuals who have a familial history with hoarding disorder are more likely to develop the same hoarding tendencies in their early life. Compared to those who don’t report having at least one first- degree relative with hoarding disorder, hoarding symptoms are less severe. There is an association between having family members with hoarding tendencies and personally displaying the same, or similar, hoarding behaviors, signs, and symptoms.
Hoarding Disorder: Nature vs. Nurture
Like most neuropsychiatric disorders, hoarding disorder appears to arise from an interaction between nature and nurture. A combination of biological and environmental circumstances is instrumental in the causation of hoarding disorder and a potential diagnosis.
Biological Etiology of Hoarding Disorder
About 50% of people with hoarding disorder have a first-degree relative who also has complex hoarding symptoms. Statistical data from twin and family studies demonstrate that vulnerability to hoarding disorder is familial, with around half of the variance accounted for by genetic susceptibility factors. Twin studies suggest that more or less than half of the risks associated with an individual’s genetic makeup is shared with OCD and other obsessive-compulsive–related disorders, while the other 50% is exclusive to hoarding disorder. The hereditary engineering of hoarding disorder is complex, with many genetic variations adding to hoarding disorder susceptibility. To date, no clear genetic risk factors for hoarding disorder have been identified.
Environmental Etiology of Hoarding Disorder
The environmental etiology of hoarding disorder has been even less clarified than the biological contributors of hoarding disorder. While a few studies argue that elevated rates of stressful and traumatic life events contribute to the onset of hoarding disorder, others show that once age is controlled for, the rates of trauma are not significantly elevated in hoarding disorder. Even if new-onset hoarding practices have been accounted for in people with head trauma or brain lesions, primarily in the inferior prefrontal cortices, these cases represent just a small fraction of individuals with risky hoarding practices. Maladaptive beliefs about keeping, as opposed to discarding materials or passionate connections to their belongings, characterize hoarding behaviors. Even though these diagnostic characteristics don’t present themselves as a substantial portion of the environmental hazards of hoarding disorder, early work on brain lesions and hoarding practices has been valuable in explaining the pathophysiology of hoarding disorder.
The cognitive-behavioral model of hoarding, initially put into place in 1996 and abridged by Michael G. Wheaton, hypothesized that hoarding is conceptualized as a multifaceted problem. Wheaton summarized that these behaviors stem from information and cognitive processing deficits, problems in forming emotional attachments, behavioral avoidance and erroneous beliefs about the nature of possessions. Both genetic and environmental information-processing deficits communicate with maladaptive beliefs about belongings to limit sentiments of guilt or anxiety related to discarding, hoarding or saving behaviors. This model, while not yet experimentally approved, contains many of the core components observed by clinicians and researchers among individuals with hoarding disorder.
Hoarding Disorder: Impact on Function and Quality of Life
The psychosocial needs of an individual need to be met in order to find happiness within themselves and in the environment around them. In hoarding disorder, the interrelation of social factors and individual thought and behavior is negatively impacted.
- Eviction: Failure to pay rent or abide by the terms of their lease results in legal expulsion from the home. In some cases, eviction can lead to homelessness.
- Financial stressors due to excessive acquisition: Limited financial resources may place a strain on the relationships between individuals with hoarding disorder, family members, and significant others.
- Risk of fire hazards: Cluttered living spaces increase the likelihood of a fire, impede escape in the event of a fire, and hinder access for both fire and medical first responders during emergency situations.
- Unsanitary living conditions and health code violations: Pest infestations, toxic odors, mold growth, and food contamination are just some of the factors that violate health code and contribute to unsanitary living conditions.
- Risk of injury: Clutter increases the risk of falling which could be especially harmful to the health of older adults.
- Loneliness and social isolation from family members and friends: Embarrassment and shame surrounding the clutter and hoarding behaviors keep these individuals from leaving their home or inviting visitors in.
- Divorce: 33% of individuals report their marital status as divorced because of the extreme impairments of functioning caused by the clutter.
- Removal of children from the household by government officials: Given all the negative consequences of living in clutter, a possible removal of children from the home can occur.
- Low income: Up to 40% of individuals with hoarding disorder live in poverty due to high levels of medical disability, work impairment, or unemployment.
- Self-neglect: Self- neglect and low self-esteem related to pathological hoarding can be a significant contributor to morbidity and mortality.
- Medication Misplacement: Following a strict schedule surrounding medication intake may be especially challenging for elderly individuals with hoarding disorder. Given their cluttered living environments, they are more prone to medication mismanagement.
Hoarding Disorder: Diagnosis
Historically, hoarding practices have been associated with to OCD and OCPD; hence, the therapeutic approaches used to evaluate obsessive-compulsive symptomatology have generally been used to assess hoarding disorder. Even though these measures do not fully assess all of the independent criteria of hoarding disorder, they do possess sufficient practical utility. Consider these various approaches to hoarding disorder treatment:
Hoarding Disorder: Self- Report Questionnaires
Counselors should administer these 3 self- report questionnaires to patients before and after treatment:
- The Saving Inventory-Revised (SI-R): Used to assess hoarding behaviors in clinical and nonclinical samples, the SI-R consists of 23 questions that are scored on a 5-point Likert-type scale. From 0 to 4, with 0 being None and 4 being Almost All/ Complete, participants rate the extent to which the three core symptoms of difficulty discarding, the presence of clutter, and acquisition affects their lives. A consistent, reliable, and valid correlation between clutter and difficulty discarding items was shown through this measure.
- The Savings Cognitions Inventory (SCI): A 24-item self-report questionnaire with four subscales: emotional attachment, memory, control, and responsibility, assesses the beliefs and attitudes that clients experience when trying to discard items. The savings cognitions inventory is proven to have high internal consistency and overall, good discriminant validity.
- Depression and Anxiety Stress Scales (DASS-21): Recognizably different in nature, the DASS- 21 is a 21-item self-report questionnaire with three psychometrically distinct subscales: depression, anxiety, and stress. Each subscale has high internal consistency and overall, the scale has concurrent validity in the acceptable to excellent range. The depression and anxiety stress scale measure the effects of depression, anxiety, and stress on hoarding disorder.
Hoarding Disorder: Secondary measures
The following secondary measures send the counselor on a psychological journey in recognizing and enabling the possible predictors of treatment response and characteristics of trial participants.
- The Memory and Cognitive Confidence Scale (MACCS): This 28-item self-report questionnaire assesses the confidence and perfectionism in a range of cognitive domains.
- The Yale-Brown Obsessive Compulsive Scale: Psychologists who use this scale assess the severity of obsessive and compulsive symptoms in individuals with hoarding disorder. Such questions include: How much of your time is occupied by obsessive thoughts? How much distress do your obsessive thoughts cause you? How much control do you have over your compulsions?
- Obsessional Beliefs Questionnaire (OBQ- 44): Clients self-report their beliefs associated with OCD on three subscales: responsibility, control of thoughts and perfectionism. The OBQ-44 measures the beliefs that are considered important in the development and maintenance of the obsessive-compulsive disorder.
- Quality of Life Enjoyment and Satisfaction Questionnaire: Through this 23-item self-report survey, convalescents will rate life satisfaction and their perceived quality of life in various areas of daily functioning.
- The HRS-I: A semistructured interview, consisting of five rated questions (1 = none, 9 = severe), assesses the level of difficulty in discarding possessions, excessive acquisition of objects, emotional distress regarding disposal of items, significant clutter in living space, and significant impairment of functioning, all of which directly align with the DSM-5 criteria for hoarding disorder. An independent rating of hoarding severity can be further determined by additional probing questions asked by the counselor. These follow- up questions are based on their own clinical judgment. The HRS-I displays high internal consistency with good reliability, validity, and strong clinical utility for counselors to assess hoarding disorder and to measure treatment gains.
Hoarding Disorder: Behavioral Tasks
During a behavioral task, the client is faced with a difficult task of discarding an item. The patient will identify an item that is of value but is at the low end of importance. A log will be provided to the patient that tracks their thoughts, feelings, and behaviors when thinking about discarding the “lower risk” item. At the next counseling appointment, all parties will thoroughly review the log together. A detailed record keeps track of the success that he or she did or did not have in discarding the low- risk item. This information can be used to identify the severity of symptoms, the level of client insight into their hoarding behaviors, and bring awareness to the client about his or her symptoms and the change process.
Secondhand reports from other healthcare providers: When assessing hoarding disorder, clinicians reap benefits from consulting with other medical experts. Secondhand reports from other healthcare providers give answers to the unknown medical history of the patient. As a result, counselors will be able to fill in missing pieces to the hoarding disorder puzzle and connect certain physical health conditions to the psychological aspects of hoarding disorder.
Secondhand reports from loved ones: These secondhand reports have an especially unique perspective into the lives and struggles of individuals with this disorder. Consent, granted by the client, gives counselors the green light to consult with family members and friends about any struggles and hardships that might have contributed to the onset, severity, and nature of the client’s hoarding disorder. Because of the manifestations and symptomatology of individuals with hoarding disorder, counselors should integrate multiple sources of information to ensure an accurate diagnosis of hoarding disorder.
Hoarding Disorder: Treatment
Hoarding disorder: Cognitive Behavioural Therapy (CBT)
A CBT approach for hoarding disorder focuses specifically on clients’ problematic beliefs and behaviors related to hoarding, avoidance of emotional distress, and potential information-processing deficits. Cognitive behavioral therapy is effective in treating hoarding disorder but multiple nonrandomized wait-list studies imply that treatment refusal and noncompliance continues to temper with treatment gains and their long-lasting effects. This specific CBT approach focuses on symptom reduction in the three major tokens of hoarding: clutter, difficulty discarding items, and excessive acquisition.
The treatment components of CBT include:
(a) Skills training with reinforcement to enhance problem-solving, decision making, and organization
(b) Imagined or direct exposure to distressing stimuli
(c) Cognitive restructuring of hoarding-related beliefs.
Hoarding Disorder: Motivational Interviewing Strategies
Motivational interviewing focuses on empowering patients. The incorporation of home visits and motivational interviewing strategies into basic CBT strengthens treatment outcomes. Through this untraditional treatment plan, therapists will show empathy towards clients, support and develop discrepancies, deal with resistance, support self- efficacy, and develop autonomy. Motivational interviewing methods address poor homework compliance, limited insight, and hesitations to proceed with treatment.
Hoarding Disorder Steketee and Frosts’ Protocol and Recommended Treatment
Steketee and Frost found that 26 weekly sessions of both office and in-home visits produce the most effective outcomes. In a qualitative study of clinician and client perceptions of CBT treatment for hoarding disorder, clients reported that they perceived home visits that address goal setting, treatment planning, and generalization of exposure exercises to be the most helpful components of this type of treatment. Home visits allow clinicians to view the nature of their clients hoarding disorder first hand. Home-based therapy enhances and maintains client motivation, provides help with discarding and organizing, and assists in applying skills at home. Although in-home visits are not always ideal for counselors, in-home assistance complements treatment outcomes. In addition, peer-facilitated support groups provide an adjunct service to treatment that potentially enhances treatment outcomes.
In closing, both individual and group CBT has been found to be beneficial in the treatment of those who have hoarding disorder. Group CBT interventions may be especially useful in addressing accompanying social impairment, withdrawal, and even comorbid depressive symptomatology. Although group CBT is somewhat less compelling than individual treatment for hoarding disorder, it meets the requirements for a more cost-effective alternative and decreases stigma, shame, and social isolation.
Hoarding Disorder: Pharmacotherapy
Granted that there are currently no medications that treat hoarding disorder, there is some evidence that hoarding symptoms can improve with pharmacological interventions. With that being said, counselors should use the following pharmacological interventions with caution.
Extended-release venlafaxine (Effexor XR), a serotonin and norepinephrine reuptake inhibitor, is viable in enhancing hoarding symptomatology. Moreover, paroxetine (Paxil), a selective serotonin reuptake inhibitor, has shown adequacy in refining hoarding side effects and comorbid depressive and anxious symptoms. In view of high comorbidity rates with other mental health disorders, extended-release venlafaxine and paroxetine might be helpful in treating co-happening features.
Analysts have yet to investigate a blend of counseling and pharmacological medications. Early theories demonstrate that joining the two intercessions could be more successful than either treatment methodology alone. As of now, no treatment contrasts have been accounted for in view of sexual orientation, race, or ethnicity.
Hoarding Disorder: Family Based Approaches
As seen in clinical case studies, family-based treatment approaches might be particularly helpful in children and adolescents with hoarding disorder. An adjusted CBT approach was utilized by Ale and his colleagues. Parental psychoeducation was incorporated to train guardians in how to adaptively respond to their kids’ problematic practices. In Ale’s clinical case study, he announced that hoarding practices in children were regularly strengthened by their parent’s responses. Therefore, parents ought to be taught that surrendering to their child’s hoarding practices adversely fortifies hoarding practices.
A reward system may be incorporated into this treatment approach as well. Ale suggested that parents should set deadlines for the disposal of certain items to set and reinforce boundaries. No clinical preliminaries have investigated the viability of family-based approaches; thus, these findings should be approached with caution.
Hoarding Disorder: Multidisciplinary Community Based Approaches
Since hoarding disorder impedes an assortment of life regions, includes the use of community resources, and frequently requires the help of experts from several practices, a multidisciplinary community-based approach might be valuable intending to hoarding disorder.
Bratiotis speculated a multidisciplinary way to address hoarding disorder that is similar to the approaches used to address social problems such as domestic violence and child abuse. Notwithstanding the medical and mental health needs of the hoarding disorder population, services relating to cleaning out and organizing the clutter are useful. For that reason, psychological institutions will prepare groups of non-counselors to assist in these missions or offer guidance to family members to enrich treatment effects.
Bratiotis reported that the first task force was formed in 1999 and that 85 hoarding task forces currently exist across Canada, the United States, and Australia. Because no clinical trials have explored the effectiveness of multidisciplinary community-based approaches, this approach warrants further research and exploration.
Hoarding Disorder: Comorbidity
In a clinical setting, hoarding disorder must be differentiated from other neuropsychiatric disorders that possibly manifest with eminent hoarding behaviors. Hoarding Disorder can be easily confused with other mental and emotional disturbances.
Hoarding Disorder and Neurodevelopmental Disorder
Just like individuals with hoarding disorder, personages with neurodevelopmental disorders may exhibit difficulty with discarding objects. Those with autism spectrum disorders or intellectual disabilities may collect items that are unusual or seemingly worthless. Unlike those with hoarding disorder, difficulty discarding these items is typically due to extreme attachment to specific objects or types of objects, not a generalized difficulty with discarding them.
Hoarding Disorder and Schizophrenia/Psychosis
Individuals with schizophrenia and other psychotic disorders may hoard items as a result of their delusions and/or negative symptoms. Imagine this: an individual feels that they are being spied upon at home so they purchase vast amounts of sheet metal to board up their windows. Item accumulation serves a specific purpose in these delusions, even if it is not the intended use of the object. Stein, Laszlo, Marais, Seedat, and Potocnik found a universality of hoarding behaviors in 5% of patients with schizophrenia symptoms admitted to a psychiatry inpatient unit.
Hoarding Disorder and OCD
Hoarding behaviors are often associated with contamination or fear of harm (eg, storing of potentially contaminated items to prevent infection). In a patient with hoarding disorder and OCD, their distress arises from a need to perform hoarding compulsions or associated hoarding obsessions rather than from difficulty discarding. Men and women with hoarding disorder have more of a fixed pattern of symptoms, are distressed by the act or thought of discarding items rather than by the act of collecting or saving them, and do not engage in ritualistic behaviors when saving items. An emotional attachment to objects is rare among cases of hoarding disorder that co-occur with OCD. Hayashida, Kiriike, Nagata, and Stein reported that 18- 40% of OCD patients also display hoarding symptoms.
Hoarding Disorder and Depression
Clutter is the result of low energy and lack of motivation to clean and/or organize rather than a result of difficulty discarding.
Individuals with hoarding disorder are five times more likely to seek mental health services than the general population. They typically seek out counseling to treat comorbid mental health disorders. Counselors should address hoarding disorder and comorbid symptoms at the same time to ensure favorable treatment outcomes. Weighting the probability of one disease versus that of other diseases signals specific hoarding disorder behaviors and behaviors that originate from other disorders.
Limitations on Hoarding Disorder Research
A few confinements have been noted inside the hoarding disorder literature. Research participants are more likely to be female, highly educated, and Caucasian, which may limit the generalizability of findings to the larger population. Having a disproportionate number of female representatives in hoarding disorder research explains gender differences in treatment-seeking attitudes. Additionally, the reliability of non-randomized control studies has not been proven in addressing the treatment of hoarding disorder at this time. Unlike a true experiment where participants are assigned to an experiment or control group, randomized controlled trials do not take place. Sample sizes in quasi-experimental studies are generally small, which may limit the generalizability of results.
Based on these limitations, additional research is needed on hoarding disorder treatment. Rigorous research studies would be helpful in determining the most efficacious remedies for hoarding disorder.
Hoarding disorder: Implications for Counselors
First and foremost, counselors working under hoarding conditions must estimate the nature and abilities of hoarding disorder environments before addressing mental health concerns. An establishment of healthy routines and client safety, by the counselor, will help to address underlying medical conditions as well. After these implications are put in place, counselors can take multiple aspects of hoarding disorder into consideration through a comprehensive assessment approach.
Counselors should take a combinational approach to assess the client’s situational context. Self-report measures and interviews, used in conjunction with behavioral tasks and reports completed by secondhand parties, will thoroughly appraise the functions and dynamics of the hoarding behaviors. A counselor will then be able to make an accurate diagnosis and develop a treatment plan for their clients.
Psychologists may need to reevaluate their own clinical expectations for treatment. In this specific group of people, treatment gains often occur slowly and will require significant dedication and work from their clients. For realistic expectations to take place, counselors need to monitor the working alliance throughout the counseling process; look for opportunities to increase clients’ insight into their behaviors and consequences; use of motivational interviewing to increase ambivalence and change language; answer questions clearly and assign homework appropriately; work on goals that are collaborative in nature; and seek appropriate self-care, supervision, and consultation throughout the treatment process.
Counselors must be patient in working with hoarding disorder patients. In a survey study, mental health professionals reported high levels of frustration when working with clients who have hoarding disorder. Providers’ frustrations can negatively affect the work alliance and prevent a positive attitude towards the counseling experience on both the clients’ and counselors’ end.
Finally, hoarding disorder specialists should carefully consider any emotional discomfort experienced by the patient, social contributors, and the social consequences of hoarding disorder. They should also include other comorbid symptoms and difficulties when determining the best treatment interventions and relapse plans.
8 Tips on Hoarding Disorder
In this section, you will find helpful tips on how to declutter your home and overcome your hoarding disorder. Before we dive into the following self-help tips, I want you to ask yourself these questions when deciding whether to let an item go:
- On a scale from 1 to 10, how bad do you need the item?
- When was the last time you used the item?
- How likely is it that you will use the item again in the future?
- What is the purpose of the item?
- What are the positives of keeping the item?
- What are the negatives of keeping the item?
With that being said, here are 8 tips on how you can help yourself from a hoarding disorder:
1. Realize the difference between compulsive hoarding and collecting.
As you become deeply submerged in your hoarding addiction, an accumulation of unused items constitutes a safety and fire hazard. When you collect an item, you’re constantly using items that have value.
2. Make immediate decisions about mail.
When we pick up freshly delivered mail from the mailbox, we tend to scan through the pile, pick out what’s important, and leave the rest on the table until next weeks delivery. For those with hoarding disorder, pick out what’s important and dispose of unwanted mail immediately.
3. Think twice about what you allow into your home.
Do you really need that two dollar angel statue that you found at Home Goods? Or that 3 dollar garden gnome because it was “on sale?” Before you decide to purchase an item, ask yourself the questions stated above. In any event that you decide to purchase something new, swap the newly purchased item with one that already exists in your home. Rather than adding to the pile, you are taking strides to minimize the amount of clutter that already exists.
4. Don’t overthink.
If you endure a long and exhausting thought process for each and every item, you will never free yourself from the clutter. Be strict with yourself and allow a couple of minutes to decide if you’re going to keep the item or not.
5. Devote 15 minutes a day to declutter.
Do not declutter your entire house in one day for this can be an extremely overwhelming and anxiety-ridden process. Instead, assign each 15-minute interval to a small portion of your home so you can really dissect each pile and pick out what’s important. This tip helps to ease anxiety and feelings of regret.
6. Handle objects only once.
Make a decision in the present so you don’t have to handle these items again and again in the future.
7. Put undecided objects in a box.
If you feel that you can’t let go of an item just yet, put it in a box and return at a later date for a final decision. This will give you more than enough time to really think about its importance and value.
8. Consider counseling.
Compulsive hoarding is a potentially serious mental health condition. If you feel that your hoarding disorder is spiraling out of control, get help from a counselor who is experienced in the treatment of compulsive hoarding disorder.
Have you or a loved one ever struggled with hoarding disorder? Let us know in the comments below!
Early Onset Hoarding Disorder
Grisham and colleagues interviewed a group of individuals, ages 26- 71, with compulsive hoarding problems about their recall of the onset and progression of their symptoms. Research showed that between the ages of 10 and 20, all three essential hoarding symptoms (clutter, saving, difficulty discarding) occurred. Symptoms of saving had a significantly later reported onset than symptoms of difficulty discarding or clutter. Grisham reasoned that the lion’s share of these individuals reviewed that their compulsive hoarding symptoms started before the age of 20. However, this examination did not require the simultaneous presence of each of the three side effects required for a DSM-5 diagnosis.
In 2010, Ayers and other associates studied the same factors as Grishman but in Ayers case, he focused on 18 older adults ranging from ages 60- 87. All participants in this sample recalled that the onset of their hoarding symptoms began before age 30 and that clutter, saving behaviors, and difficulty discarding items appeared to steadily increase across their lifespan. Unfortunately, there was no differentiation between the types of hoarding symptoms, and no demographic differences were examined in either the age of onset or progression of hoarding symptoms.
In a study conducted by Tolin and fellow partners, data was gathered through an online sample of primarily mid-life individuals with self-identified hoarding problems. 70% of members announced that their hoarding behaviors began before the age of 21. 73% revealed an interminable course of hoarding manifestations, however, 21.2% reported that symptom severity increased as they got older. This study was limited in that all questions were self-reported and no differentiation was made between the three core symptoms of hoarding.
The prior three studies lead by Grisham, Ayers, and Tolin suggest that hoarding symptoms generally begin early in the lifespan and increase across time. However, findings from these studies were influenced by certain approaches that were taken to investigate the onset of hoarding behaviors. The onset of clinically severe hoarding was not examined in a way that’s consistent with the DSM-5 diagnostic criteria for hoarding disorder. Further, Ayer and Tolin did not review the three primary symptoms of hoarding disorder separately or whether an association existed between basic demographic variables and course of symptoms.
Late Onset Hoarding Disorder
As opposed to the evidence presented by Grisham, Ayers, and Tolin, several scientific studies have presented reports of late-onset hoarding. In a current study coordinated by Anderson and Damasio, the relationship between aging and hoarding symptoms explained the progression of hoarding disorder across the lifespan. Demographic differences in the development of initial symptoms and the course of hoarding disorder are other factors that define this relationship.
In 19 self-reports of late-onset hoarding, all three symptoms occurred simultaneously after the age of 40. Prior to the age of 40, 68% of these individuals experienced urges to save items, 21% experienced excessive clutter, and 37% reported difficulty in discarding. Anderson and Demasio noticed a trend in those whose symptoms were not present until after age 40. Major life changes, for instance, retirement, losing a job, or kids leaving for college, were possible late onset etiology.
All 19 participants in Anderson and Demasio’s study showed that hoarding symptoms increase over time. Through utilization of T-tests that compared symptom severity in the fifth and sixth decades, clutter continued to increase with each decade of life, while symptoms of saving and difficulty discarding stabilization in the fifth decade of life. Between the fifth and sixth decade, reports of remission or symptom decrease were not found.
In general, the progression of symptoms and hoarding severity increases across the lifespan. Clients report that their clutter continues to pile up over the years and before they know it, they are living in a pile of their own belongings. Clutter seems to be the only core symptom that increases in severity but some report that saving and difficulty discarding stabilize in later adulthood. Researchers are still unsure if this stabilization is part of the natural disease progression or the result of psychosocial factors that may inhibit acquiring and artificially increase discarding. Prospective longitudinal studies will be needed to definitively characterize the onset and progression of hoarding disorder symptoms.
Moulding, R., Nedeljkovic, M., Kyrios, M., Osborne, D., & Mogan, C. (2017). Short-Term Cognitive-Behavioural Group Treatment for Hoarding Disorder: A Naturalistic Treatment Outcome Study. Clinical Psychology & Psychotherapy, 24(1), 235-244.
Sumner, J. M., Noack, C. G., Filoteo, J. V., Maddox, W. T., & Saxena, S. (2016). Neurocognitive performance in unmedicated patients with hoarding disorder. Neuropsychology, 30(2), 157-168. doi:10.1037/neu0000234
Novara, C., Cavedini, P., Dorz, S., Pardini, S., & Sica, C. (2017). Structured Interview for Hoarding Disorder (SIHD): An Italian Validation With Diagnosed Clinical Patients. European Journal Of Psychological Assessment, doi:10.1027/1015-5759/a000433
Dozier, M. E., Porter, B., & Ayers, C. R. (2016). Age of onset and progression of hoarding symptoms in older adults with hoarding disorder. Aging & Mental Health, 20(7), 736-742. doi:10.1080/13607863.2015.1033684
Kress, V. E., Stargell, N. A., Zoldan, C. A., & Paylo, M. J. (2016). Hoarding Disorder: Diagnosis, Assessment, and Treatment. Journal Of Counseling & Development, 94(1), 83-90. doi:10.1002/jcad.12064
McCarty, R., & Mathews, C. A. (2017). Hoarding Throughout the Life Span. Psychiatric Times, 34(9), 35-38.
Linda is currently a student at Stony Brook University, studying a Bachelors in Psychology. Through her writing, she hopes that she will be able to expand her own knowledge on the motivation behind human behavior and how the brain works. She hopes that she will be able to inform others about psychology- related topics in a fun, easy, and creative way.