Hoarding disorder occurs when an individual experiences a persistent difficulty to let go of items leading to a continuous possession of objects regardless of their value. Often, the thought or act of discarding the possessions causes extreme stress, which the individual avoid by holding on to the item. The Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM 5) criteria for diagnosing hoarding disorder include excessive reluctance to part with possessions, stress, or distress when letting go of the items. The individual also tends to accumulate the items disrupting movement of space at home, and separation of hoarding from other mental disorders. Furthermore, a significant percentage of patients engage in the excessive acquisition of items such as shopping or collecting of their preferred items without necessarily having a use for them (Timpano & Schmidt, 2013). Common symptoms include avoiding visitors at home, indecisiveness on places to store objects, desire for isolation, feelings of anxiety from the idea of losing the possessions, and depression. Before recommending therapies for treating the condition, it is important first to understand the types and causes of hoarding disorder.
Causes of Hoarding
Extensive research and literature exist on the causes of hoarding, mainly focusing on the clinical and cultural underpinnings of the disorder. The etiological association between hoarding and deficits in self-control was investigated by Timpano & Schmidt (2013), who found that the reduced ability to control urges plays a role in the development and maintenance of hoarding. Limited abilities in exerting self-control often result in individuals experiencing difficulties controlling their urges, as is the case with drug and alcohol addictions. Patterns of uncontrollable urges to retain possessions are common in hoarding patients. As such, poor self-control emerges as a significant contributing factor to hoarding behaviours. While an individual with hoarding disorders may experience the need to change their approach in terms of possession and to let go, the powerlessness in the face of the urges eventually draws them back to the hoarding behavior. Repeated patterns of failure to deal with their inclinations eventually causes the person to lack the motivation to change their behaviour completely. Another explanation of the relationship between hoarding and self-control lies with the control of cognition abilities (Timpano et al., 2011). The patients lack the ability to gain control of underlying thoughts hence allowing undesirable patterns of thought to take over. The lack of self-regulation also grows with time until the adverse effects become apparent to others.
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The association between hoarding behaviours and genetic factors has also emerged as an interesting part of the investigations of the causes of the disorder. The neurotrophic factor (BDNF) is responsible for neuron transmissions in the brain and has a crucial role in the development of special neural signals (Timpano et al., 2011). As such, neuron functioning is considerably affected by BDNF, and a variation in the neurotrophic factor can provide a genetic explanation for hoarding behaviours. Studies have found that variations in chemicals that control BDNF distribution in the nervous system can affect brain functioning (Timpano et al., 2011). As such, changes in brain chemicals due to mutations affect the distribution of BDNF, thus affecting normal functions and the ability to control hoarding behaviour. The occurrence of hoarding behaviour between siblings provides crucial genetic evidence of the role of the neurotrophic factor (BDNF) in hoarding. It is, however, difficult to determine whether genetic factors alone can result in hoarding disorder. For instance, an individual with the genetic mutation that exposes him to a greater risk for hoarding will not develop the disorder when living in settings where there are patterns of possessing or disposing of items. The genetic link, however, provides invaluable knowledge that can inform decisions on treatment and interventions for hoarding patients. Notably, genetic factors contribute up to 47% of hoarding cases in adults and up to 67% in children (Taylor et al., 2010). The difference may be attributed to the ability of the adult to control certain factors or conditions that may expose them to hoarding behaviours.
A combination of genetic and environmental factors that influence psychopathology also explains the occurrence of hoarding disorder. Negative emotionality is on such factor that increases the risk for developing hoarding behaviours (Taylor et al., 2010). Negative emotions such as feeling irritated, depression, and anxiety as a result of a range of unexpected events such as frustrations and loss can lead to hoarding. For instance, an individual may hoard items after the loss of a loved one if they are unable to move on from experience. Alternatively, individuals develop hoarding behaviours as a coping mechanism when they experience life frustrations or feel anxious. Perspectives into culture can also provide explanations for the causes of hoarding. Cultural perspectives, such as ideas about value and waste, can cause the development of hoarding behaviours (Orr et al., 2019). In a society where people place considerable personal value on possessions, individuals with genetic exposition to hoarding behaviours are at greater risk of developing the disorder. They are unlikely to create a distinction between hoarding and collecting; hence will view the behaviour as harmless. Notably, such societies, the differences between hoarding and collected are not obvious. Hoarding behaviour thus becomes common, leading to a false feeling of normalcy by the patients. They thus continuously suffer the negative effects of the disorder either without seeking the help of others noticing.
Types of Hoarding
Hoarding types relate to the kind of items that the individual accumulates and the reason for possession of the items. The apparent differences between hoarding and collecting are that collectors usually organize their items and are aware of their features and location while hoarders pile their items and are unlikely to identify them for their values. The different types of hoarding include animal, paper/books, shopping, over-sentimental, typical, and non-wasting hoarding.
Animal hoarding is the most common type of accumulation where the order keeps a large number of animals in a confined space such that they do not receive adequate amounts of care as recommended by veterinaries. Most Animal hoarders are pet lovers and usually intend to care for the animals but under the wrong conditions. Having a large number of animals within spaces both the animal owner and the pets in danger of diseases and injuries. There is a reduced chance the animals will receive adequate grooming, cleaning, and waste management. The animals quickly accumulate viruses and bacteria that are a danger to the owner and others that they contact. Paper or book hoarding is among the most observed hoarding that can occur either in leaving spaces or other places within the home. The disorder is common among researchers and ardent readers. While storing reading materials can serve a positive purpose, paper hoarding is characteristically disorganized, and the individual can hardly retrieve the material for future reading. The improperly stored papers accumulate dust, which poses a health risk to individuals and can cause physical harm through falls.
Oversentimental hoarding is often the result of traumatic experiences, as described by Brien et al. (2018) or memories of certain periods or events. The patient uses the accumulated item as a reminder of either a loss or a tool for covering the traumatic experience. The result is that individuals end up with a large quantity of useless items to which they attach great importance. They are, however, affected by the fear of losing the items, although they are hardly able to recognize the specific item related to each memory. Such is usually the case when hoarders intend to keep memories of a happy period but end up with a large number of worthless items. Typical hoarding, of the other hand, is the result of indecisiveness that prevents the person from identifying the items to keep and others that should be discarded. Over time, it becomes impossible to arrange or sort the items. The accumulation of items takes up valuable living spaces and while placing the individual at risk through infections and fires.
Non-wastage hoarding, just like paper hoarding, is built on the notion that the objects might be of use in the future. The order accumulates worthless items with the excuse that they can find new uses. The items rarely find use and take up a lot of space that would be used for other purposes. Food hoarding also falls under non-wastage, where individuals store excessive amounts of foods than they need. Although the intention is usually to avoid waste, most of the food expires; hence the behavior fails to serve its purpose. Shopping hoarding is another type of clutter accumulation that can be detrimental to the individual. The behavior is a result of self-control or deficits in self-regulation during shopping (Timpano & Schmidt, 2013). Often, the patient purchases a large number of items that they hardly require. Over time the items accumulate and form clutter. The owners rarely give out the items due to the fear associated with losing them hence continue to hold on to them while they hardly need them. The items accumulate dust, which causes a health risk or expire and lose value.
Therapies and Common Interventions for Patients
Various treatment methods for hoarding behaviors exist depending on the decision of the physician based on the severity of the condition and suitability for the patient. Common therapies and interventions include cognitive-behavioral therapy (CBT), cognitive rehabilitation, pharmacological treatment, and family and group support (Barbra et al., 2018).
CBT for hoarding disorder patients includes a set of interventions that aim to change the path of thinking for the patient. Professional assessments, formulation of personal models, providing motivation for behavior change, and prevention of replaces are some of the key strategies applied under CBT for hoarding patients. Ata the assessment stage, the therapist reviews the symptoms and their impact on the daily life of the client. The review also aims to determine the severity of the problem. The therapist then formulates a personalized model for the client, where they explain the cause of the problem and how it developed (Bratiotis et al., 2016). The patient is then taken through procedures that aim to reduce their acquisition behaviors. Processes may vary at this stage depending on the client, but common procedures include visiting the client’s home, tour to dirty places, and training on organization skills. Once positive progression is achieved, sessions continue to ensure full recovery and prevention of relapses. The downside of this therapy is that rates of clinical improvement are usually between 23-34% improvements in functional impairment (Barbra et al., 2018). The correct application of the CBT can, however, cause significant changes in compulsion hence treating the disorder.
Cognitive rehabilitation therapy is widely applied to older adults with hoarding problems, although the intervention has produced mixed results (Barbra et al., 2018). There are no specific procedures for CRT for older adults with hoarding disorder. The therapy follows two main treatment goals, restorative and compensatory treatment. Under restorative treatment, the therapists aim to improve the cognitive abilities of the hoarding patient such that they desist from acquisition behavior. Compensatory treatment, on the other hand, trains the client on techniques to remind them against accumulation behaviors such as using notebooks or other items for a reminder. Family support can also function as a non-professional level intervention. Family members can discourage the patient from accumulating items by making them aware of the adverse effects of the behavior. Over time, the patient develops a habit of avoiding hoarding behaviors.
Pharmacological treatment applies a range of medications to overcome hoarding behaviors. These are mainly drugs applied for patients with compulsive tendencies to improve their self-control. Common drugs include paroxetine, venlafaxine, and methylphenidate (Barbra et al., 2018). Pharmacological treatment showed a considerably high success rate in terms of improvement of the patients’ symptoms. The treatment time is also much favorable than cognitive methods, where improvements begin to emerge after eight weeks (Barbra et al., 2018). On the flip side, the medications have a range of side effects, including fatigue and drowsiness, which might discourage patients from continuing.
Conclusion
The fine line between hoarding and collection highlights the importance of identifying acquisition behaviors in their early stages and applying appropriate interventions. The causes of hoarding disorder, both genetic and environmental, point to a gradual progression of the problem. While different factors may contribute to the problem in various individuals, making them aware of its adverse effects can significantly impact on treatment and intervention strategies. Considering that there is a range of objects which can be hoarded, individuals need to aware of the possibility of collecting behavior turning into hoarding. As such, hoarding disorder, the development and progression of hoarding disorders can be curbed through a whole range of intervention strategies.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®) . American Psychiatric Publication.
Bratiotis, C., Davidow, J., Glossner, K., & Steketee, G. (2016). Requests for help with hoarding: Who needs what from whom? Practice Innovations, 1 (1), 82-88. doi: http://dx.doi.org.ezproxy.stfrancis.edu/10.1037/pri0000017
Brien, C., O'Connor, J., & Russell-Carroll, D. (2018). “Meaningless carrying-on”: A psychoanalytically-oriented qualitative study of compulsive hoarding. Psychoanalytic Psychology, 35 (2), 270-279. doi: http://dx.doi.org.ezproxy.stfrancis.edu/10.1037/pap0000100
Orr, D. M., Preston-Shoot, M., & Braye, S. (2019). Meaning in hoarding: perspectives of people who hoard on clutter, culture and agency. Anthropology & Medicine , 26 (3), 263-279.
Stumpf, B. P., Hara, C., & Rocha, F. L. (2018). Hoarding disorder: A review. Geriatrics, Gerontology and Aging , 12 (1), 54-64.
Taylor, S., Jang, K. L., & Asmundson, G. J. G. (2010). Etiology of obsessions and compulsions: A behavioral-genetic analysis. Journal of Abnormal Psychology, 119 (4), 672-682. doi: http://dx.doi.org.ezproxy.stfrancis.edu/10.1037/a0021132
Timpano, K. R., & Schmidt, N. B. (2013). The relationship between self-control deficits and hoarding: A multimethod investigation across three samples. Journal of Abnormal Psychology, 122 (1), 13-25. doi: http://dx.doi.org.ezproxy.stfrancis.edu/10.1037/a0029760
Timpano, K. R., Schmidt, N. B., Wheaton, M. G., Wendland, J. R., & Murphy, D. L. (2011). Consideration of the BDNF gene in relation to two phenotypes: Hoarding and obesity. Journal of Abnormal Psychology, 120( 3), 700-707. doi: http://dx.doi.org.ezproxy.stfrancis.edu/10.1037/a0024159
