Hoarding Disorder

The essential feature of hoarding disorder is having great and persistent difficulty throwing out (or otherwise parting with) objects, regardless of their actual value. While the prospect of throwing something out may give rise to a lot of distress, there is also anxiety about selling, giving away, or recycling items.

 

Typical behaviours seen in compulsive hoarding

  • Saving far more items than are needed or can be used.
  • Getting more items (in addition to already saved objects) than can be used.
  • Avoiding throwing things away.
  • Avoiding making decisions about objects or other life matters
  • Slowness (or lateness) to complete tasks, and
  • Difficulty categorising or sorting possessions into appropriate storage (e.g. closets, drawers)

 

What Drives Compulsive Hoarding?

The main reasons given by hoarders for their hoarding difficulties are:

  • The perceived usefulness of the object – e.g. “I might need it one day.” Many individuals also save large numbers of things that are objectively valuable or useful as well, and these are often mixed together with less valuable things.
  • The fear of losing important information – e.g. needing an item to remember something.
  • The feeling that throwing something out is ‘wasteful’ – no matter how valuable or unusable, an immense guilt is felt at the prospect of being wasteful.
  • The characteristics of the object – e.g. liking the way it looks or feels. Moreover, if there is a particular quality to an object (e.g. texture) these may be of particular value to the hoarder and therefore make up a larger part of their collection.
  • The sentimental value (emotional properties) of the object – hoarders often feel responsible for the ‘fate’ of their possessions. People with hoarding also often attribute living properties to non-living items, so they may feel like the item is left to ‘die’ if they don’t collect it. On the other hand, discarding an object can feel like they are hurting or ‘killing’ it.

Objects can also be linked to particular memories for the person, such as positive memories of a relative. In these instances, there’s often fear about throwing the object out should it make them disappoint, hurt or otherwise lose the person linked to the object. By extension, thinking about throwing something away can feel to the hoarder like throwing ‘someone’ away – there is subsequent fear of loss, loneliness or abandonment.

The most commonly saved items are newspapers, magazines, old clothing, bags, books, mail, and paperwork, but virtually any item can be saved (including rubbish, pieces of paper or broken bits of items). Some hoarders also hoard animals, for which they are unable to provide adequate care and sanitation.

 

Controlling Urges

It is very difficult for hoarders to control the compulsion to acquire something. At the time of getting something, they feel strong positive emotions, and these emotions are very reinforcing over time. For hoarders, it can be like a ‘high’, such that this euphoria dominates other information being processed at the time that might otherwise curb the urge.

 

Course of Hoarding

Hoarding appears to begin early in life and can span into later ages. Research shows hoarding symptoms first emerge around 11–15 years of age and show different patterns thereafter (e.g. times when the hoarding lessens and times when the hoarding is worse, depending somewhat on life events and stress).

 

Impact of Hoarding

Hoarding makes basic activities of daily living difficult – moving through the house, cooking, cleaning and sleeping. In severe cases, hoarding means the person is at increased risk for fire and poor health.

As mentioned above, the objects for a hoarder can be sentimental in linking the hoarder to a loved one. The paradox here is often that the person’s hoarding over time means that their house becomes so full that their relationships to these loved people are negatively impacted. For example, friends can’t visit any more because there’s no space in the hoarder’s house, or the hoarder feels ashamed to have people visit.

Family relationships are frequently under great strain. Conflict with family, friends, neighbours and local authorities is common. This can also depend to some degree on whether the person acknowledges that their hoarding beliefs and behaviours are a problem (some people do not see their hoarding as problematic). Individuals with severe hoarding disorder are typically involved in legal eviction proceedings, and some have a history of eviction.

 

Other Difficulties related to Hoarding Disorder

Other factors associated with hoarding include difficulty making decisions, plans and categorisations, perfectionism, procrastination, avoidance and being easily distracted. For example, some individuals who hoard may show symptoms of Attention Deficit Hyperactivity Disorder (ADHD).

Of every 4 people diagnosed with Hoarding Disorder, 3 will have an anxiety disorder or mood disorder. Hence it is very common for individuals with hoarding to have a history of anxiety. Many are also depressed. Being depressed may not be the cause of hoarding but more so a result of the hoarding, which has negatively impacted the person’s social and occupational functioning and reduced their quality of life.

Hoarding Disorder is not diagnosed if it is directly linked to neurodegenerative conditions (e.g. Alzheimer’s disease or following brain surgery). It is common for individuals with dementia to develop accumulating behaviours and rituals.

Compulsive Shopping is also different to Hoarding Disorder. While both difficulties have some similarities, the causes, behaviours and consequences in each disorder are distinct.

Finally, Hoarding Disorder used to be a subtype of Obsessive Compulsive Disorder (OCD). However, research has shown the two disorders are distinct, both in the neural (brain) pathways that underpin them and in their set of symptoms. However, it is common that individuals with OCD and Hoarding Disorder both experience feelings of ‘incompleteness’, and thereby are compelled to document or preserve all their live experiences. If hoarding symptoms appear alongside OCD (but the two are distinct) both diagnoses are given. If the person’s hoarding symptoms are seen to be a direct result of the person’s obsessions and compulsions (e.g. fearing contamination or harm in OCD), a separate diagnosis of Hoarding Disorder is not given.

 

Treatment for Hoarding

Research has shown that Hoarding Disorder is best treated using Cognitive Behaviour Therapy (CBT). This therapy involves (but is not limited to) the following strategies:

Cognitive Restructuring: Exploration of beliefs about hoarding and changing any unhelpful beliefs. This technique decreases excessive fears about making decisions, losing important possessions, throwing things away, and organising saved items.

Behavioural Experiments and Exposure: People who suffer from Hoarding Disorder tend to avoid situations or triggers that make them feel anxious, angry, distressed, etc. Over time, however, we cannot avoid difficult emotions. Behavioural experiments involve testing out an alternative way of behaving so the person can see whether their feared predictions actually come true (e.g. in throwing out that t-shirt, was their sister angry with them or was their relationship lost?). In the same vein, exposure involves gradually and slowly exposing someone to their anxiety about throwing away items or the urge to acquire things. For example, if the person is compulsively acquiring recyclables, exposure strategies may begin with learning to throw out one piece of recycling and tolerate the emotions associated with this. Later sessions may involve going to a recycling depot and walking away without ‘rescuing’ an object. Over time, the feelings a person brought to therapy (e.g., low coping and a sense of hopelessness) are replaced with feelings of agency, control and confidence.

Stress Management: Compulsions tend to worsen when a person is stressed. Learning effective ways of coping is important and are done collaboratively, with the support of your therapist.

Relaxation and Emotion Management Skills: These skills help to decrease anxiety, tolerate distress and learn more helpful and effective ways of dealing with both positive and negative emotions that may be linked to the hoarding. Learning to tolerate uncomfortable emotions can be done in the therapy room and practised outside of sessions.

Decision Making Skills: Learning ways to problem solve (without hoarding) is paramount. There are a variety of strategies that can be learned through therapy that are useful, practical and sustainable in everyday life. Having these skill sets also means that when stress comes in the future, there is a helpful management tool kit.

 

The Role of Medication

A combination of medication and CBT appears to be the most effective treatment regimen for most people with Hoarding Disorder. Antidepressant medications (e.g. Serotonin Selective Reuptake Inhibitors or SSRIs) have been shown to be helpful in conjunction with CBT. However, taking medication depends on the needs of the individual, the severity of their problem and their attitude towards taking medication.

 

Where to Go From Here?

If you would like to find out more about our treatment for Hoarding Disorder, or to book an appointment with one of our Clinical Psychologists who can provide treatment for this condition, please email or call us on 0405 430 530.  We understand that it may be difficult to make it to our St Leonards clinic for treatment, therefore we also offer the option of holding SKYPE consultations with our clinicians. Please let us know if this is the best option for you.

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