Buried Alive: Hoarding As a Mental Disorder

by Haifa Haroon on March 30, 2013

Here’s a question for you: When was the last time you gave your inbox a deep clean?Or, unsubscribed from the several mailing lists that you’ve stopped checking. Although I try to make the ‘tough’ decisions to keep mine organized, after a while, it can be easy to come up with an excuse to not hit delete.

I’ll come back to it later. What if I need it someday? Must back it all up – twice! 

Although this a relatively harmless example of hoarding, extreme forms of this behavior in the physical world is a serious health concern. Excessive hoarding, which you may be familiar with from the A&E TV show, Hoarders, is the collection of large amounts of items without being able to throw them away.

Courtesy of jezebel.com

The new DSM, the diagnostic manual of mental disorders used by health professionals, will include hoarding as a disorder.

DSM-V hasn’t been released yet, but the proposed criteria for diagnosis include:

  • Continuous difficulty throwing away objects, regardless of their value

  • Collecting large quantities of items that take up personal surroundings (eg. home, work, car etc) and prevent you from properly using the space

  • Hoarding effecting safety and your social interactions

  • Behavior is not due to general medical conditions (eg. brain injury)

  • The symptoms aren’t explained by another medical condition (eg. obsessive-compulsive disorder (OCD), depression etc)

Approximately 6 million people in the United States may be classified as hoarders. Hoarding usually develops around age 13 -14 and tends to get worse with age. The cause of the behavior isn’t clear, but individuals with the disorder tend to have at least one relative with similar habits. When it develops later in life, it is usually after a stressful event such as an eviction, divorce, the death of a loved one or brain injury (though the latter is excluded from the DSM  diagnostic criteria).

Hoarders tend to save junk mail, newspapers, magazine, craft items and even animals. They report doing this for different reasons – emotional significance, they may need it in the future, it may be valuable later on or they may feel safer with them around.

Courtesy of TLC

Distinguishing Between Hoarding and Obsessive-Compulsive Behavior

Until recently, extreme hoarding was thought to be a symptom of OCD (and, obsessive compulsive personality disorder). You may even see it referred to as “compulsive hoarding”. However, study findings show that they are independent conditions.

Only about 18% of hoarders meet criteria for OCD. The majority of hoarders (80%) don’t have the repetitive behaviors of OCD. People with OCD repeat behaviors in order to reduce some perceived threat or anxiety. They realize that their actions are irrational and therefore, are more likely to seek help.

On the other hand, people with hoarding disorder (HD) amass objects for various reasons and they experience positive emotions when hoarding. The objects or behavior itself isn’t an issue for them – but, the resulting mess and conflict with family members over the hoarding may be distressing. These people don’t see their behavior as a problem, which presents a challenge for treatment.

Additionally, brain activity differs between people with OCD and HD when making a decision. Tolin et al. (2012) had participants bring in some of their possessions, like a newspaper or junk mail. While monitoring their brain activity, they were shown images of things (things they owned and other items) and  had to decide whether or not to have it shredded. The researchers found that hoarders were less likely to shred their own items than the OCD and normal (control) group. They also had more activity in two areas of the frontal lobe of the brain – the anterior cingulate cortex (ACC) and in the insula – when making a decision about their belongings, but less activity in these areas when making a decision about items that weren’t theirs. These areas are believed to be involved in decision making and emotion processing.

So, when hoarders were presented with their items, they experienced abnormal brain activity, which affected their decisions – placing very high value on the items and therefore making it difficult to get rid of it. They also took longer to make the decisions and reported feeling sad and anxious.

These results are generally supported by other studies. People that are engage in pathological collecting tend to be afraid of making mistakes, have difficulty completing tasks and take longer to categorize items (making it difficult to organize). Many of these people have other disorders as well. In a study, Forest et al. (2011) found that 50% of hoarding patients also suffered from major depression, 28% met the criteria for attention deficit hyperactivity disorder (ADHD), while a smaller proportion were diagnosed with a general anxiety disorder and social phobia.

Animal Hoarding

Impact on health

Over time, excessive hoarding can have an impact on your emotional and physical health. People with HD have a lower marriage rate and the condition may lead to social isolation (though, it could be a result as well).

They are also more likely to be overweight and suffer from medical conditions such as hypertension, arthritis, diabetes and chronic fatigue syndrome. Due to the crowding at the home, people with HD are at a higher risk of falling. This is also a safety issue because exits may be blocked and therefore, there is a higher from a fire.

Safety is especially important with  animal hoarders. Over 50% of their homes tend to have feces, urine and dead animals on the floor. In this situation, exposure to diseases from the animals is a concern.

Treatment

There isn’t a set treatment though interventions, OCD medication and therapy have been used. With the inclusion of HD in the DSM-V, hopefully, treatment options specific to the disorder will be developed.

John McKay March 31, 2013 at 12:24 am

I’m still unclear about the difference between hoarding because of hoarding disorder (HD) and hoarding for other reasons. People who experience HD hoard because of the positive feelings that they experience by keeping certain items near them. People with other disorders hoard because of the negative feelings involved with disposing with certain items. Am I right so far?

The shred or not shred choice seems like a false dichotomy. Many hoarders resist debulking (I think my mother coined that term) because of a hyper-sentimental feeling toward the objects at hand. That is to say, for many, debulking isn’t a binary choice of keep or destroy; it’s a three-way choice of keep, find a new home for, or destroy.

You say that only about 18% of hoarders meet criteria for OCD. What about depression, dysthemia, bipolar, and other anxiety disorders?

Finally, on the issue of organization; the stereotype of hoarders is that they live in unsanitary disordered environments. Where do very organized hoarders–those with their own systems of shoe boxes and file cabinets–fit into the schema? Are they HD, CDO (you know the joke). or something else?

I’m not trying to be critical of you. I’m genuinely concerned about the direction DSM-5 is going.

Megs Little March 31, 2013 at 1:34 am

I have a hoarding disorder – in my case, mostly, it’s an inability to dispose of anything (old correspondence, outdated electronic components etc) which might by any conceivable chance be wanted again and which – or so I fear – would not, in that case, be replaceable.
However, I also have an urge towards neat surroundings and so indeed, as your previous correspondent suggests, what I live amongst is unmanageable quantities of files, ring-binders and stacking plastic boxes, endlessly and minutely labelled and covering every wall (horizontal surfaces stay clear).
I am approaching the end of my life and worry quite a lot about the people who will be required to clear this lot up (in fact they will probably take it to the tip, ring-binders, boxes, labels and all).and I also occasionally worry about the odd confidential item included in the correspondence but I cannot, for the life of me, deal with the problem myself.
I always thought it was obsessive compulsive, combined with insecurity and an inability to move on. I wonder what others suggestions your readers may have. other suggestions?

Angela March 31, 2013 at 6:07 am

I have to aunts who identify themselves as having a hoarding disorder. One of them is a psychiatric nurse actually, so she has really good insights into what is going on. One strategy she has developed is to give things away as gifts. Either unmodified or modified through craft practices (e.g. old calendar sheets turned into gift bags or origami), so that the separation from the items does not become so emotionally traumatic. In turn, producing and giving gifts implies that you go out for more social events.

Toms Shoes Sale May 19, 2013 at 3:40 am

We didnt expect it to take off as well as it did, she said.

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