What is Hoarding Disorder?
Persons with hoarding disorder find it difficult to part with possessions. Often these items are of little value. Even normal persons may collect items, but their collection is purposeful and organized. They take pride in their collection. It does not inconvenience them. But, in hoarding disorder, the items clutter the living areas. One cannot use such living areas fully.
Items that are most often hoarded are newspapers, magazines, paper, plastic bags, cardboard boxes, photographs, household supplies, food, and clothing. Some may hoard animals. People feel upset or anxious if you attempt to clean it up.Hoarding disorder starts usually in middle-age. It occurs in 2-6% of the population. Hoarding disorder can be comorbid with OCD.
People who hoard are perfectionists. They dread making wrong decisions. They fear wasting things or losing items that might be “important”. These worries lead to behaviors like indecision, not getting rid of things, and collecting objects that may be of value only later on.
Symptoms of Hoarding Disorder
- Inability to discard possessions that they no longer use.
- Severe anxiety when attempting to discard items
- Great difficulty organizing or categorizing possessions
- They buy many of the same things again and again because they cannot lay their hands on what they already have.
- The clutter prevents them from having friends or relatives over at their place.
- Functional impairments, including loss of living space, family or marital discord, financial difficulties, health hazards, falls and even fire hazards.
- There could be narrow “trails” in the house to make their way between tall mounds of stuff.
- They may feel out of control or embarrassed when they look at their piles of clutter.
- Obsessive thoughts and behaviors, such as fear of running out of an item or checking the trash for accidentally discarded objects
Causes of Hoarding disorder
The exact cause of hoarding disorder is unknown. People may hoard thinking an item may come in handy later on. Or they may feel sentimental about it, or think it is unique and irreplaceable. They may keep it to jog their memory, so as not to forget an important event or person. Or they cannot decide where something belongs and hence keep it where it is.
Risk factors include:
- Indecisive personality or temperament.
- Family history of the disorder.
- Stressful life events, such as the death of a loved one, divorce, eviction or losing possessions in a fire.
Diagnosis of Hoarding Disorder
DSM-5 lists the following diagnostic criteria for hoarding disorder:
- Persistent difficulty discarding or parting with possessions, regardless of their actual value.
- The difficulty is because of a perceived need to save the items and the associated distress when trying to discard them.
- This results in more items that clutter living areas and interferes with their intended use unless third parties intervene.
- Hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).
- The symptoms are not because of another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).
- It is not better explained by the symptoms of another mental disorder, e.g., OCD, major depressive disorder, schizophrenia or another psychotic disorder, neurocognitive disorder, autism spectrum disorder.
Treatment of Hoarding Disorder
Selective serotonin reuptake inhibitors (SSRIs) are the first-line of treatment for hoarding disorder. Venlafaxine also may be efficacious for this disorder. Some studies have noted a response to glutamate modulators.
Cognitive-behavioral therapy (CBT) helps in hoarding disorder. Components include psychoeducation and goal setting, organization skills training, practice with resisting acquisition, and cognitive restructuring. Given that many patients have limited insight, use motivational interview techniques to engage patients in treatment. Involving family members and social services may be key, particularly when insight is absent.
In the absence of definitive studies on this method of treatment, clinical judgment has to be used to determine the optimal sequencing of different modalities.